Most if not all of today's vascular practices spend considerable portions of their clinical schedules addressing occlusive disease in the superficial femoral artery (SFA). SFA disease is increasingly prevalent, as well as more frequently found, with awareness increasing from the patient level to primary physicians and hospitals. There is still considerable work to do in this regard, but the fact remains, we are treating more SFA cases than ever. We also have more tools on our shelves, allowing us to tailor treatment to the seemingly infinite variety of lesions we encounter in this challenging anatomy.

However, it is not always easy to decide which device or combination of devices suits the specific sets of anatomy and lesion characteristics that are seen every day. To make these decisions, we sift through datasets that exist along a spectrum of disparity, ranging from robust to nonexistent. While the strongest data from randomized trials have been illuminating, these trials do not always address the lesions we most often encounter in daily practice. To understand the strengths and weaknesses of every option, we must carefully consider all of the data at our disposal, but also look to the experiences of our colleagues. With that in mind, we have asked a respected group of authors to candidly discuss some of the pressing questions facing today's peripheral interventionists.

We begin our SFA feature with a roundtable discussion including Gary M. Ansel, MD, FACC; Michael D. Dake, MD; Lawrence A. Garcia, MD; Peter A. Schneider, MD; and myself in which we address the issues currently facing interventionists who encounter SFA disease in their daily practice.

Next, Jihad A. Mustapha, MD, FACC, FSCAI, provides an overview of the atherectomy devices on the market today and how a slow and thorough procedural method produces optimal outcomes. James E. Moore Jr, PhD; Scott E. Anderson, PE, BME; and Michael R. Moreno, PhD, explain the biomechanical factors associated with treating SFA disease and the way devices have evolved to meet the needs of this complex and dynamic vascular territory. 

Crossing femoropopliteal chronic total occlusions remains a challenge in many cases. However, there is no clear consensus on whether and when an intraluminal or subintimal approach is the most efficacious technique for treatment. John P. Pigott, MD, FACS, reviews the advantages and disadvantages associated with each approach.

Another challenge of treating SFA disease comes into play when a previously stented segment restenoses. Although there are several methods currently being used to address this situation, there is no clear-cut best option, nor much if any data to support our anecdotal experiences. Faramarz Tehrani, MD; Khung Keong Yeo, MD; and I take a look at some of the options currently being used to address in-stent restenosis.

Dovetailing with our article, we have asked a respected panel of interventionists to describe which therapeutic option they most often use to treat SFA in-stent restenosis. After reading each of their approaches, please feel free to weigh in with your own preferred method on our Web site, www.evtoday.com.

Outside of our cover feature this month, we have an update on the diagnostic and therapeutic options available for pelvic congestion syndrome from Colleen J. Moore, MD. Then, we have a challenging case presented by Donald J. Voelker, MD, FACC, FSCAI, FSCCT, FASA; Rajiv K. Sharma; Nicky Pipkin, MD, FACS; Harvinder Dod, MD, FACC; and Rakesh K. Sharma, MD, FACC, FSCAI, FSCCT, in which they treat multiple aneurysms using endovascular repair with the snorkel technique.

We conclude with an interview with Hence J.M. Verhagen, MD, PhD, who discusses patient selection in aortic aneurysm pathologies, treatment techniques, and tools used when there is difficult vascular anatomy to contend with.

As always, we hope you find this issue to be a good, practical read.