Lesions of the Superficial Femoral Artery: Which Ones Need Treatment and How

Abstract

Atherosclerosis isolated to the superficial femoral artery (SFA) typically manifests as calf claudication. Unless associated with other levels of vascular disease, SFA atherosclerosis is usually not limb or life threatening. However, physicians are under increasing pressure to treat individuals suffering from claudication because of the availability of newer endovascular approaches, which have the strong appeal of minimally invasive insertion and short hospi tal stays. However, the natural history of patients with claudication suggests that in the absence of diabetes and tobacco use, the limb loss rate for this sub set of patients is very low. In the presence of tobacco use, limb loss rate increases to 4% over a 5-year period; in the presence of diabetes, it increases to approximately 35% over the 5-year period. Patient-specific factors which pre dict SFA lesion progression include: contralateral SFA occlusion, symptom pro gression, and smoking history. Lesion-specific factors which predict SFA lesion progression include only lesion location in the adductor canal. Other lesions located elsewhere in the SFA despite initial severity of stenosis, typically progress at a very slow rate and are unlikely to occlude. Treatment of mild to moderate claudication should be discontinuation of tobacco products and reg ular exercise. In patients who are refractory to this regimen, duplex study of iliac and superficial femoral artery may uncover a lesion amenable to endovas cular treatment. Percutaneous angioplasty, if used, should be performed in patients with lesions that correspond to Category I and II of the American Heart Association Task Force Guidelines: isolated short stenoses or occlusions in patients with good runoff. Stents and stent grafts have not been shown to improve the patency of percutaneous angioplasty in SFA lesions and should be used only for suboptimal technical results. Femoral-popliteal bypass remains the "gold" standard for treatment; vein bypass typically performs better than prosthetic material and should be used in patients in whom prosthetic bypass has been shown to be suboptimal. These include women, young smokers, and patients with impaired outflow.