Femoropopliteal PTA

1
Femoropopliteal PTA
3y FU
Fontaine IIb
2
IndicationsTASC J Vasc Surg 2000

• Type A Endovascular therapy (ET) is the
  treatment of choice
• Type B ET is more commonly used but more
  evidence is needed to make any firm
  recommendations
• Type C Surgery is more commonly used but more
  evidence is needed to make any firm
  recommendations
• Type D Surgery is the treatment of choice

3
IndicationsTASC J Vasc Surg 2000

• Type A
• Single stenosis up to 3 cm in length
• Type B
• Single stenosis or occlusion up to 10 cm long
• Heavily calcified stenosis up to 3 cm long
• Multiple stenoses or occlusions each less than 3
  cm long
• Single or multiple lesions to improve inflow for
  distal surgical bypass

Type A
Type B
4
IndicationsTASC J Vasc Surg 2000

• Type C
• Single stenosis or occlusion
• gt 10 cm long
• Multiple stenoses or occlusions, each 3-5 cm
• Type D
• Complete CFA and/or SFA occlusion
• Complete popliteal and proximal trifurcation
  occlusion

Type D
Type C
5
PTA ResultsTASC J Vasc Surg 2000
6
Stents
Primary indication bail out
7
Stents

• Complications
• thrombosis
• intimal hyperplasia

1y FU
Lysis
48hr
Stent
8
Stents ResultsTASC J Vasc Surg 2000
9
PTA/Stents claudicationMuradin et al,
Radiology 2001
PTA Stent Stenosis patency range patency ra
nge 1y 77 78-80 75 73-79 2y 66
63-71 67 65-71 3y 61 55-68 66
64-70 4y 57 54-63 -- -- 5y 55
52-62 -- -- Occlusion 1y 65 55-71 73
69-75 2y 54 45-61 66 61-68 3y 48
40-55 64 59-67 4y 44 36-53 -- -- 5y
42 33-51 -- --
10
PTA/Stents critical ischemiaMuradin et al,
Radiology 2001
PTA Stent Stenosis patency range patency ra
nge 1y 60 46-63 74 68-80 2y 49
35-54 66 59-72 3y 43 30-51 65
58-71 4y 40 26-46 -- -- 5y 38
24-44 -- -- Occlusion 1y 47 41-51 73
68-75 2y 36 28-41 65 60-68 3y 30
20-37 63 58-68 4y 27 16-34 -- -- 5y
25 13-32 -- --
11
PTA and Stent for Treatment of Femoropopliteal
artery disease Meta-AnalysisMuradin et al,
Radiology 2001

• Conclusion
• PTA and stent implantation for claudication and
  stenosis yield similar long-term patency rates
• for more severe femoropopliteal artery disease
  (occlusion, CLI) the results of stent
  implantation seem more favorable

12
PTA vs Palmaz stent in femoropopliteal arteries.
Randomized trialCejna et al JVIR 2001

• Inclusion criteria
• claudication or CLI
• sfa or proximal pa
• up to 3 lesions (stenosis/ occlusion)
• lt 5 cm
• gt 1 patent run-off vessel
• intention to treat

• Endpoints of the study
• primary endpoint 12 months primary patency
  rate
• secondary endpoints primary technical success
  rate complication rate secondary patency
  rate

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PTA vs Palmaz stent trialPrimary technical
success rate
Limbs (n 154)
Primary PTA (n 77)
Primary stent (n 77)
succesfull (n65) 84.4
succesfull (n76) 98.7
p0,02
secondary stent implantation (n 10) 13.0
residualstenosis (n 1) 1.3
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PTA versus Palmaz stent -primary angiographic/
US patency
63
15
PTA versus Palmaz stent -primary hemodynamic/
clinical patency
77 72
16
PTA versus Palmaz stent -secondary angiographic/
US patency
86 79
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PTA vs Palmaz stent trialCejna et al JVIR 2001

• Conclusion
• Primary stent placement significantly decreased
  technical failure rate (p lt 0.02)
• Primary stent placement did not improve mid-term
  angiographic and clinical/hemodynamic success
  rate
• Secondary stent placement
• is indicated if PTA fails
• reveals results similar to PTA

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Complications
n all major surgery death PTA Becker 4662 10.0
5.6 2.5 0.2 Capek 152 5.5 Matsi
106 10.5 4.0 2.0 Matsi 295 10.5
(CLI) 0.5 (CI) Johnston
236 6.3 Hunink 106 2.4 Gardiner 3.0 TAS
C 1241 4.3 Stents Strecker
80 8.8 Cejna 141 2.6 Henry
126 14 Lammer 74 2.1 TASC 585 7.3
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PTA/Stents in femoropopliteal arteries

• Conclusion
• short lesions (lt 3cm, type A) are ideal
  indications for endovascular treatment
• in claudicants patency rates are similar for PTA
  and stents (gt 60 at 3y)
• in more severe disease (type B and C, CLI)
  stents or stentgrafts may be more favorable
  (patency of 73-75 at 1y)