Page 2 - Carotid and peripheral vascular interventions textbook

CHAPTER 1 2
CAROTID AND PERIPHERAL VASCULAR INTERVENTIONS: STEP-BY-STEP

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.