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Does Early Failed Endovascular Treatment Of The Superficial Femoral Artery Affect Subsequent Revascularization Options And Patient Outcomes?

Charles S Joels, John W York, Corey A Kalbaugh, Eugene M Langan, III, David L Cull, Bruce A Snyder, Anna L Cass, Christopher G Carsten, III, Spence M Taylor.
GHSUMC, Greenville, SC.

OBJECTIVES:  It is generally accepted that failed infrainguinal bypass significantly compromises arterial run off, which may limit future revascularization. Conflicting evidence exists regarding the effect of failed peripheral angioplasty on the run off status. The purpose of this study is to determine whether early failure after superficial femoral artery (SFA) intervention influences subsequent revascularization options.

METHODS:  Between July 1, 1998 and June 30, 2006, 276 patients underwent endovascular intervention of the SFA. To determine the optimal distal bypass location, a prospective analysis of pre-intervention and post-failure angiograms of patients with early failure (within 200 days) was performed in a blinded fashion by three attending vascular surgeons. Inter-rater reliability of the angiogram scores was assessed using Fleiss’s generalized kappa for multiple raters. Potential distal anastomotic sites were classified as above knee (AK) popliteal, below knee (BK) popliteal, tibial or no adequate site. A consensus classification was determined for each patient (2 out of 3 raters).

RESULTS: Of the 276 patients who underwent endovascular intervention of the SFA, early failure was noted in 23 patients/24 limbs. Angiographic records were available for 20 patients/21 limbs (65.3 + 11.3 years, 60% male, 60% critical limb ischemia, 40% claudication, 65% diabetes). The distal bypass site was altered in six (28.6%) limbs; four from popliteal to tibial and two from AK to BK popliteal. Inter-rater reliability was 0.54, considered moderate/good. The procedures performed on these early failures were PTA +/- stent (n=14), infrainguinal bypass (n=5), and no treatment (n=1). Only 0.4% (1/276) of patients required major limb amputation due to early failure of an SFA intervention.

CONCLUSIONS: Early failure after isolated endovascular intervention of the SFA is infrequent and rarely alters the distal target if open bypass is planned. Salvage with repeat angioplasty, if necessary, can be accomplished in the majority of cases, and the need for limb amputation is exceedingly rare. This study supports a more liberal application of endovascular intervention to the SFA in patients with lower extremity ischemia, especially claudication.