title: Unique demands of the femoral anatomy and pathology and the need for unique interventions.
abstract: With the aging of the population the incidence of peripheral artery disease (PAD) is increasing, which is histologically characterized by fibrocalcific intimal plaques as well as underlying Mönckeberg's medial calcinosis as compared to coronary and carotid artery disease. Superficial femoral artery (SFA) is one of the longest and most dynamically active vessels in the body undergoing torsion, compression, flexion, and extension from leg motion, and is known to be more susceptible to atherosclerosis because of low shear stress or spiral flow, best appreciated in the long segment in its lesser curvature. Endovascular interventions are now considered the first-line strategy for the treatment of PAD patients presenting with claudication or critical limb ischemia, where physiologic stresses on the arterial wall, anatomic considerations, and lesion characteristics impact on their success. Stent fracture and malapposition, are a common phenomenon in PAD which are attributed to severe calcification and fibrosis along with greater motion of the lower extremity, that result in the dampening of the efficacy of stenting and balloon angioplasty. Better designs of self-expanding stents have resulted in either reduction in stent fracture rates or its elimination at least in the short-term follow-up studies, to date. Although drug-eluting stents (DES) have reduced restenosis rates in the coronary circulation, this benefit has not been consistently observed in PAD. However, recent clinical studies utilizing novel Zilver-PTX self-expanding stent (DES) have demonstrated favorable patency rate. Also, in patients with critical limb ischemia, better outcomes have been reported for below-the-knee utilization of DES. Nevertheless, drawbacks of stent technology remain and interests in the greater use of drug-coated balloons (DCB) for PAD have emerged. Randomized controlled trials have consistently shown superiority of DCB over uncoated balloons in reducing neointimal formation in patients with SFA disease. Moreover, there is a growing interest in atherectomy as an alternative treatment strategy for PAD, thus decreasing plaque burden with possibly avoidance of barotrauma. The results from registries support the effectiveness of the atherectomy devices; however, prospective randomized controlled trials are needed to confirm their benefit.
authors.affiliation: CVPath Institute, Inc, Gaithersburg, MD 20878, USA. rvirmani@cvpath.org
authors.forename: F
authors.initials: F
authors.lastname: Otsuka
authors.forename: M
authors.initials: M
authors.lastname: Nakano
authors.forename: K
authors.initials: K
authors.lastname: Sakakura
authors.forename: E
authors.initials: E
authors.lastname: Ladich
authors.forename: F D
authors.initials: FD
authors.lastname: Kolodgie
authors.forename: R
authors.initials: R
authors.lastname: Virmani
mesh_terms: D000800:Angioplasty, Balloon; D000818:Animals; D017073:Atherectomy; D050197:Atherosclerosis / Q000473:pathology / Q000628:therapy*; D054855:Drug-Eluting Stents; D004868:Equipment Failure; D005260:Female; D005263:Femoral Artery / Q000473:pathology*; D006801:Humans; D008297:Male; D058729:Peripheral Arterial Disease / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D015607:Stents; D014945:Wound Healing