Wei-guo Fu, MD

Zhongshan Hospital
Fudan University
Shanghai, China
He has stated that he has no financial interests related to this article.
Dr. Fu may be reached at fu.weiguo@zs-hospital.sh.cn.

What is the prevalence of endovascular SFA therapy as compared to surgical?

It has become an assumption that endovascular therapy for SFA disease is the first-line strategy, including cases of intermittent claudication and rest pain. Bypass surgery is now only used if endovascular therapy fails. Currently, a growing number of patients with TASC C or D lesions successfully undergo endovascular therapy. The midterm patency rate is also increasing with the use of new devices such as drug-coated balloons (DCBs) and drug-eluting stents (DES). Patency will improve further if functional biomaterial scaffolds and biodegradable stents become available.

How would you describe device availability in your country, both in types of devices and different vendors within each class?

Fortunately, almost all of the devices from various manufacturers are available in China. Some self-developed products are undergoing clinical trials.

In what ways does reimbursement (both government and private if applicable) affect device use? Which device classes are most affected?

The reimbursement system in China varies by region. With the implementation of the New Rural Cooperative Medical System, almost all devices are covered by reimbursement for all “in-hospital patients” in China. Catheters, balloons, and stents are reimbursed, but some new devices (eg, DCBs, DES, and closure devices) are currently not reimbursed. However, the reimbursement system will enroll these devices in the future, and they will be covered based on their general applications.

Are there any historic or cultural forces unique to your country that have affected the penetration of endovascular options?

Endovascular therapy is a safe, minimally invasive, feasible option that enables treatment for a large percentage of older patients who are not candidates for bypass surgery. Device advancement and universal popularization of the reimbursement system (eg, the New Rural Cooperative Medical System) also enhance the penetration of endovascular options.

How do most physicians receive training in endovascular therapies in your country?

In China, some vascular centers, such as Zhongshan Hospital, PLA 301 Hospital, and Anzhen Hospital, offer fellowship training every year. As a training center, we receive more than 200 scholars from all over the country annually and host a grand academic meeting (China Endovascular Course) every 2 years, which showcases basic and advanced technologies, operation recording, and live programs from the top three largest vascular centers in China. Peripheral endovascular procedures are almost always performed by vascular surgeons and, to a lesser extent, by interventional angiologists.

What is your personal strategy or algorithm for treating SFA disease?

• Short, focal lesions: PTA with or without DCBs for short lesions with good outflow; stenting only for the flow-limiting lesions post–balloon angioplasty

• Long lesions: Mainly bare-metal stenting and PTA for the nondissecting, non–flow-limiting lesions post–balloon angioplasty, according to digital subtraction angiography or intravascular ultrasound. The use of DCBs is increasing based on the promising outcomes from global registry data

• Calcified lesions: Sufficient balloon angioplasty (long inflation time and enough pressure) followed by stenting; the better compression-resistant stents may be chosen for calcified lesions

• CTOs: Subintimal recanalization and angioplasty with stenting, using antegrade and retrograde approaches

• In-stent restenosis: DCBs for short and long in-stent lesions, stent-in-stent for proximal and distal stent restenosis, thrombectomy for some total occlusion in-stent restenosis

• Claudicants: The definition of success is different from the viewpoints of the patient and clinician. Patients may be worried about their symptoms and wish to get around without claudication, pain, or concern for amputation, whereas the clinician may expect to revascularize the narrowed or occlusive arteries. The results of preoperative examinations, such as a walking exercise test, ankle-brachial index, and CT angiography, are fully evaluated before endovascular therapy is considered. Patients only undergo invasive procedures if the results of preoperative examination predict a good outcome.