Page 2 - Carotid and peripheral vascular interventions textbook
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                    Femoropopliteal Arterial Disease

                    Thosaphol Limpijankit

                    INTRODUCTION                                    superf cial femoral artery (SFA) and popliteal artery (7).
                                                                    The CFA form as a continuation of the external iliac artery
                        Femoropopliteal arterial disease is the most common   below the inguinal ligament level. The CFA is about 4 cm
                    etiology of intermittent claudication (1,2). Greater than   in length and is located just anterior to the femoral head.
                    50% of all peripheral artery disease (PAD) cases affect the   Branches emerging from the CFA comprise deep pudendal
                    femoropopliteal arteries (3). An isolated atherosclerotic   artery, superf cial circumf ex artery, and superior epigastric
                    stenosis or occlusion of these vessels results in decreased   artery (Fig. 12-1). Distal to these small branches, the
                    proximal blood f ow in the leg, causing ischemic pain   CFA bifurcates near the bottom of the femoral head into
                    conf ned to the calf. In patients presenting critical limb   the deep femoral or PFA and SFA. The PFA gives rise to
                    ischemia (CLI), the occlusive disease of femoropopliteal   lateral and medial circumf ex arteries supplying the femur
                    artery is usually combined with occlusive disease involving   and hip regions prior to descending far within the thigh
                    the infrapopliteal tibial arteries. In general, two-thirds of   compartment then completes as penetrating deep tissue
                    symptomatic PAD patients are found to have a multi-   branches. The SFA descends along the thigh anteromedial
                    segmental disease (4). Unlike the iliac arteries, the disease   within the femoral triangle and provides a vital role in
                    in the femoropopliteal arteries is normally diffuse disease,   supplying the entire lower leg with oxygenated blood.
                    long occlusions and extensive calcif cation. It is predicted   It goes into and along the adductor (Hunter’s) canal within
                    that 50% of patients receiving femoropopliteal intervention   the adductor hiatus close by the distal thirds and middle
                    are found to have chronic total occlusions (CTOs) (5).   junction of the thigh, and converts into the popliteal artery
                        Although surgical revascularization is the principle   which runs behind the femur.
                    management for femoropopliteal disease, increasingly      One of the distinguishing features of the SFA is the
                    endovascular intervention is being used as the primary   absence of signif cant branches all along its route. This
                    treatment strategy. Over the last decades, new devices and   elucidates this vessel’s constant diameter, normally about
                    technologies have been continuously developed showing   6-7 mm. However, a number of small, muscular branches
         330        improved long-term patency, including special balloon   may be seen. The major muscular branches include the
                    angioplasty, self-expandable nitinol stents, atherectomy   sural arteries together with the paired superior, middle, and
                    devices, drug-eluting stents, and drug-coated balloons.   descending geniculate arteries, which all arise above the
                    In addition, with improvements in guidewire crossing     adductus canal and form the collateral circulation round
                    techniques, novel crossing devices, and re-entry devices, an   the knee. At the distal boundary of the popliteal muscle,
                    increasing number of challenging cases, such as complex   the popliteal artery splits into the anterior tibial artery
                    lesion or CTOs, may now be managed with endovascular   and the tibioperoneal trunk.
                    procedure (6). In the future, technological improvements      The anatomy of the deep femoral or PFA is important
                    will further improve long-term results in endovascular   since it supplies collateral f ow in the SFA CTO. Patients
                    interventions of femoropopliteal disease.       with SFA occlusions located distal to the take-off of the
                                                                    PFA and proximal to the distal reconstitution of the SFA
                    ANATOMIC CONSIDERATION                          via the profunda collaterals may remain asymptomatic

                                                                    for an extended time period. In contrast, occlusions of
                        The femoropopliteal segment comprises the common   the distal SFA involving the popliteal artery may result
                    femoral artery (CFA), profunda femoris artery (PFA),   in rapidly developing and progressing claudication.
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