Rethinking common femoral artery disease treatment: When and how to choose endovascular over open surgery?

This is an invited commentary on Tokuda T et al. ⁸ Outcomes of contemporary stents with deep femoral artery coverage. Vasc Med 2025; 30: 162-169; and Korosoglou G et al. ⁷ Atherectomy-assisted endovascular therapy versus open repair for atherosclerotic common femoral artery disease: The multicenter ARISTON study. Vasc Med 2025; 30: 170-182.

The treatment of common femoral artery (CFA) atherosclerotic lesions remains a major clinical challenge. Open endarterectomy has been the cornerstone of CFA disease treatment for decades, offering excellent long-term patency and ensuring the removal of calcified plaques that may obstruct blood flow. ¹ Its ability to preserve collateral circulation through the deep femoral artery (DFA) is critical for durable limb perfusion. However, the invasiveness of the procedure is associated with significant risks, including wound-related complications (reported in approximately 8% of cases), prolonged hospital stays, and the need for general anesthesia. According to a systematic review, the 30-day mortality rate for open surgery was 1.7%, with an early reintervention rate of 2.4% and a perioperative morbidity rate of 14%. ² Additionally, studies have shown a procedural mortality rate as high as 3.4% and severe systemic complications such as cardiovascular events, renal failure, and pulmonary complications occurring in 15% of patients. ³ These concerns are particularly pronounced in patients with multiple comorbidities, such as obesity, diabetes, or history of multiple CFA punctures. ³ In light of these limitations, endovascular alternatives have emerged as a promising option. ⁴ Recent technological advances such as atherectomy platforms, biomimetic stents, and drug-coated balloons offer the potential to reduce the morbidity associated with open surgery while delivering comparable clinical outcomes. ⁵ Unfortunately, there are few contemporary assessments of endovascular versus surgical revascularization for CFA disease, as well as endovascular approaches for complex CFA disease involving the DFA. Much of the guidance is based on older literature and expert recommendation.

Though endarterectomy remains the gold standard for CFA disease due to its durable patency, as stated, its invasiveness can lead to wound complications and prolonged hospital stays.^1,2 Endovascular options have shown promising results in select cases, particularly in patients with high surgical risk, as new technology has shown promise in improving vessel patency while minimizing the need for permanent stents.^{4 –6} Against this backdrop, two recent publications in Vascular Medicine provide further evidence regarding management of CFA disease. The ARISTON study by Korosoglou and colleagues provides a comparative evaluation of clinical and technical outcomes between endarterectomy and endovascular revascularization approaches for the treatment of CFA disease. ⁷ Tokuda and colleagues examined complex CFA anatomies involving the DFA. ⁸

The prospective, multicenter, ARISTON study by Korosoglou et al. analyzed data from 826 patients (69% [n = 570] with claudication and 30.4% [n = 251] with chronic limb-threatening ischemia [CLTI]), including 213 (25.8%) who underwent atherectomy-assisted endovascular CFA intervention and 613 (74.2%) who underwent CFA endarterectomy. ⁷ The primary findings did not demonstrate a significant difference in amputation-free survival and clinically driven target vessel revascularization rates between the two techniques at the 2-year follow up (hazard ratio [HR]: 1.5, 95% CI: 0.59–3.77 and HR: 1.46, 95% CI: 0.61–3.49, respectively). Bailout stenting, which occurred in 5.1% of cases in the ARISTON study, can complicate future interventions by restricting surgical access or increasing the risk of stent fracture in the groin area. The low bailout stent rate in the ARTISTON study is promising; however, with a short median follow-up time, durable patency has not yet been established with the approach studied.

The study by Tokuda et al. assessed technical challenges with endovascular CFA intervention, focusing specifically on the impact of DFA coverage during CFA stenting and highlighting its effects on stenosis rates and long-term limb outcomes. ⁸ Their study, which analyzed data from 457 patients (77.9% [n = 356] with claudication and 21% [n = 96] with CLTI) undergoing endovascular revascularization with stent deployment for de novo CFA lesions, found that DFA coverage significantly increased the risk of subsequent DFA stenosis (27.2% vs 14.3%, p = 0.0015). ⁸ However, at 3 years, no significant differences were observed in primary patency of the femoropopliteal artery, including the CFA (82.3% vs 80.6%, p = 0.48), target lesion revascularization rates (12.5% vs 13.8%, p = 0.72), or major adverse limb events (6.2% vs 5.9%, p = 0.81) between patients with and without DFA coverage. These findings underscore the goal of avoiding unnecessary DFA coverage during endovascular stenting of the CFA but also provide evidence that when it is necessary to do so, there does not appear to be a significant impact on long-term limb outcomes. ⁸

Stepping back, the choice between endarterectomy or endovascular revascularization in current clinical practice remains positioned around patient selection and lesion characteristics. Open surgery may be better suited for younger patients where long-term durability is paramount, or those with heavily calcified lesions where achieving a stent-free outcome can be challenging. In contrast, endovascular therapy offers faster recovery times and reduced procedural risks, making it a compelling option for patients with significant comorbidities. The trade-offs between procedural simplicity, durability, and potential complications, such as risks of long-term restenosis or stent fracture, remain central to the debate. The studies by Korosoglou et al. and Tokuda et al. illustrate these complexities, emphasizing the importance of individualized treatment plans informed by both clinical evidence and patient-specific factors.^7,8

These considerations are also reflected in the new 2024 American College of Cardiology/American Heart Association peripheral artery disease guidelines, which provide a framework for the management of CFA disease and distinguish between patients with claudication and those with CLTI. ⁹ In patients with claudication, open surgical endarterectomy remains the preferred approach and is classified as a Class 2A recommendation due to its superior long-term patency and ability to restore normal vessel anatomy without the need for permanent implants. Surgery is particularly indicated in cases where the lesion is heavily calcified, involves the DFA, or when the patient has a low surgical risk and can tolerate the procedure. Conversely, endovascular therapy is considered a Class 2B recommendation, meaning it may be an alternative in select cases, particularly in high-risk surgical patients, those with focal, noncalcified lesions, or individuals with a history of multiple groin surgeries, where another open procedure may pose additional risks. For patients with CLTI, similar factors are emphasized when determining a suitable patient-specific revascularization strategy, although timeliness and completeness of revascularization is the priority due to the concerns for limb loss. ⁹

Emerging technologies are poised to further refine the management of CFA disease. Devices designed to minimize recoil postintervention and improve drug delivery are currently under investigation.^10,11 Additionally, the combination of endovascular plaque modification with drug-coated balloon therapy holds promise for reducing restenosis rates and improving long-term outcomes. Intravascular lithotripsy (IVL) is also gaining attention as a novel approach for treating heavily calcified lesions with low risks of dissection or perforation. ¹² By using acoustic pressure waves to fracture calcium deposits, IVL facilitates vessel compliance and enhances the effectiveness of subsequent interventions, such as drug-coated technology and stenting. Studies have shown promising results, with improved procedural success rates, reduced complications related to residual stenosis or dissection, and low risk of bailout stenting. ¹²

The treatment of CFA disease is at a crossroads, with endovascular therapy emerging as a compelling alternative to open revascularization. Although open endarterectomy remains the gold standard for durable outcomes in anatomically and clinically suitable patients, endovascular approaches offer significant advantages in terms of reduced invasiveness and faster recovery times. These studies by Korosoglou et al. and Tokuda et al. not only demonstrate the potential of contemporary endovascular therapy to match the outcomes of open surgery, adding substantially to a much-needed body of evidence, they also highlight the nuanced decision-making required for CFA revascularization. The debate over durability, procedural risks, and patient selection remains central to optimizing care. As technology continues to advance, the boundaries of endovascular therapy will likely expand, offering new possibilities for improving patient care.