Exploring Options in the SFA
Along with the many well-documented anatomical challenges we encounter when treating the superficial femoral artery (SFA), today's interventionists are also faced with a practical dilemma: Which of the many available and emerging devices options should we select for a given patient?
Good clinical data are still lacking for many of these devices, but we are beginning to develop a clearer picture of which devices and strategies achieve the best results in certain settings, based upon anecdotal experience and the limited data that are available to us. Several important SFA stent randomized trials and registries have been completed, and we are approaching important follow-up milestones, with much-anticipated longer-term data on the way. Not all data are created equal, and there are pitfalls to comparing the results from these different stent trials, but certain patterns are emerging. Hopefully, in the near future, there will also be clinical trial data regarding some of the emerging technologies (such as atherectomy devices) and their effectiveness compared to stents. In the meantime, we will continue to make treatment decisions based on limited registry data, anecdotal experience, and expert opinion.
With this in mind, we have asked a group of interventional experts to discuss the clinical utility of several of today's options for treating SFA disease. They will describe for you the ideal uses of a particular device, as well as those settings in which an alternative therapeutic option is preferred. Michael C. Nguyen, MD, and Lawrence A. Garcia, MD, will start us off by summarizing their view of the optimal uses of excisional atherectomy in lower extremity arterial occlusive disease. There have been a number of important advances in balloon catheter technology over the past several years. Specialized scoring and cutting balloons are increasingly being used for a variety of lesion subsets. Drs. Bosiers, Deloose, Verbist, and Peeters discuss the role of these devices and how they can be optimally used to overcome some of the limitations of conventional angioplasty. Pranab Das, MD; Santosh K. Koshy, MD; Robert S. Dieter, MD; and Aravinda Nanjundappa, MD, present a case-based review of cryoplasty showing positive outcomes when this technology is used for the treatment of peripheral arterial disease. Gunnar Tepe, MD, and Ulrich Speck, PhD, discuss drug-coated balloons and their use in peripheral arteries, reviewing some of the literature and providing useful animal- and patient-study tables.
Next, Subhash Banerjee, MD; Emmanouil S. Brilakis, MD, PhD; and Tony S. Das, MD, explore the use of covered stents as another option for the treatment of disease in the SFA. Our SFA feature closes with updates from a few of the recent SFA trials. Krishna Rocha-Singh, MD, co-national principal investigator of the DURABILITY II trial, describes how the VIVA Physicians' Performance Goals were incorporated and how the trial will help further our understanding of stenting in long lesions. Michael D. Dake, MD, addresses the status of both the randomized trial and the global registry studying the Zilver PTX drug-eluting stent in the SFA. Finally, I will highlight some of what we have learned in RESILIENT, a landmark randomized trial of nitinol stenting versus PTA in the SFA.
Our Coding & Reimbursement column ties into our SFA feature; Jackie Miller, RHIA, CPC, discusses CMS's decision to rescind a policy change made to the Correct Coding Initiative manual in October 2007. She provides examples of how the language change affects Current Procedural Terminology coding guidelines. In our Techniques department, an article by Dr. Rosenthal and colleagues highlights the benefits of remote endarterectomy for patients with peripheral vascular disease. Our featured interview this month is with Jos C. van den Berg, MD, PhD.
We hope this issue will help answer some of the questions you face in your practice, and that we learn more together in the years to come as further data emerge regarding the optimal treatment strategies for this challenging vascular territory.