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Subintimal Angioplasty And Stent-Grafting Of Long Segment Femoropopliteal Occlusions: Technical Considerations And Four Year Results

J Timothy Riley, Rafik Moufid, Frank Tarantini, William Rodino, Thomas Panetta.
Staten Island University Hospital, Statin island, NY.

OBJECTIVES: Traditionally superficial femoral artery (SFA) angioplasty and stenting has met with poor results, especially in long segment disease. Treating long segment disease, 10 cm or greater, with subintimal angioplasty and stenting yielded marginal results when compared to the standard of open femoropopliteal bypass. Endoluminal femoropopliteal bypasses (ELFP) involve the placement of a stent graft after angioplasty of stenotic regions or subintimal angioplasty of occluded segments.

METHODS: ELFP of SFA long segment lesions with covered stents was performed in 68 patients with 75 limbs being treated since December 2002. Indications included claudication, rest pain, tissue loss and limb salvage. All candidates underwent an angiogram to determine the anatomical suitability of these lesions for angioplasty and stenting with stent grafts. Patients were considered acceptable for covered stent placement if there was minimal CFA disease, patent popliteal artery 2 cm above knee joint and patent below the knee with at least single vessel runoff. All patients were followed up at 3-month interval with PVRs and graft duplex to evaluate patency.

RESULTS: ELFP bypass was performed on 75 limbs. In our study population the occlusive lesions were multilevel with 93% of patients having SFA occlusion and 13% of patients having PFA disease. The mean length of the lesion was 30.4 +/- 14.1cm, 90% > 15cm. The stents used were 5-6 mm x 5-15 cm. The number of stents used is 2.5+/- 0.8. Adjunctive stents were used in the CFA 11%, PFA 17% and Iliac 23%, these stents were uncovered stents. During postop period the patient were evaluated every 3-month. There was marked improvement in symptoms in 56%, moderate improvement 33.3%, no change in 3.3%, mild deterioration in 3.3%, and severe deterioration in 3.3 %. The ABI increased with mean of 0.14+/- 0.16, range of ABI 0.13-0.77. The 4-year patency in patients undergoing ELFP is 78.7 %. Complications included amputations in 5 patients, 1 nonfatal MI, 1 endoleak and 2 DVT.

CONCLUSIONS: ELFP bypasses for SFA occlusive disease using ePTFE covered nitinol stents demonstrated comparable results to femoropopliteal bypass and better outcomes than PTA alone.