The superficial femoral artery is the most common lower extremity artery affected by occlusive disease in the body. The indications for treating superficial femoral artery occlusive disease with minimally invasive endovascular techniques follow classic vascular surgical guidelines for treating all lower extremity occlusive disease: lifestyle-limiting claudication, ischemic rest pain, and tissue loss. Specific treatment options include plain old balloon angioplasty, balloon angioplasty and stenting, and atherectomy. This chapter focuses on balloon angioplasty and stenting. There are limitations when considering applying minimally invasive techniques to treat superficial femoral artery blockage, and these are primarily based on anatomic variables. Specifically, lesions that are longer than 10 cm and severe calcification limit the effectiveness of using endovascular therapy. In addition, there is concern for kinking when implanting stents across the popliteal fossa. Finally, patients with extensive tissue loss have limited options, and many still consider saphenous vein bypass to provide pulsatile flow in these circumstances as the gold standard.
All patients with superficial femoral artery occlusive disease should have preoperative noninvasive physiologic studies that include ankle brachial indices with segmental pressures or pulsatile volume recordings. It has become common to also get a planning computed tomographic angiogram. For patients with claudication, the ankle brachial index is usually less than 0.7, for rest pain less than 0.5, and for tissue loss less than 0.4. It is beneficial to maximize medical therapy preoperatively, and this includes aspirin, statin therapy, and the addition of clopidogrel.
ANESTHESIA AND POSITIONING
Most lower extremity interventions for occlusive disease are done under continuous oxygen, nurse, and electrocardiogram monitoring. Occasionally, general anesthesia is applicable in high-risk or difficult patients.
OPERATIVE PREPARATION AND PERCUTANEOUS ACCESS
A Foley catheter is placed in the patient after premedication. This reduces the need for the patient to move during and immediately after the procedure, decreasing the potential for a hematoma by unnecessary movement. It is now recommended that percutaneous femoral or pedal access be done under ultrasound guided access, which decreases the incidence of hematoma or inadvertent high puncture above the inguinal ligament or low puncture in the superficial femoral artery. Both groins should be prepared and draped because both contralateral and ipsilateral approaches have been used. In general, using the contralateral femoral artery with an up and over technique is preferred (FIGURE 1A, B). Occasionally in patients with chronic total occlusions, retrograde pedal recanalization is the only option, so appropriate micropuncture needles and wire should be available. Then a time-out is performed. Patients are usually heparinized with 50 units/kg.
This section describes the contralateral up and over technique. Access to the contralateral common femoral artery is obtained first by identifying appropriate landmarks. The femoral artery typically lies 2 cm below the inguinal ligament, marked by ...