Real-World SFA Decision-Making
Across the spectrum of vascular disease, our expectations for therapeutic outcomes can vary considerably. In some cases, we are unsatisfied with anything less than a permanent resolution. More often, however, we know that some recurrence is possible—“required maintenance”—and we advise patients and plan follow-up accordingly. In the case of complex superficial femoral artery (SFA) lesions, despite having a multitude of devices to select and combine as needed, we lack a silver-bullet strategy for ensuring permanent infrainguinal revascularization. In this vascular territory, a successful result on the table does not fully rule out a future recurrence or progression of atherosclerosis.
Although a permanent fix may elude us, the improvements in quality of life that come with successful revascularization, prolonging the time to the next revascularization, or preventing the need for an open surgical procedure are significant in the eyes of our patients and their families.
In other words, while restenosis is still likely in some of our more complex cases, improvements in quality of life and health care cost savings from prolonging times between visits are worthwhile and rewarding elements of treating this challenging disease. Most peripheral interventionalists and their patients and families would clearly agree. Once the determination to intervene is made, then the more immediate question becomes how to approach the case to ensure the best short-term physiological outcome with longest durability and the least invasive procedure.
In this edition of Endovascular Today, our goal is to explore the challenges of navigating the foggy confluence of study data, device availability, and procedural reimbursement that must be considered in selecting the right course for each patient.
The patient in front of us, whose longevity and quality of life are paramount, may not match the populations described in the literature pertaining to the devices we’re considering. And often, our individual concepts for the ideal combination of devices to prolong patency will come with a price tag that exceeds available reimbursement.
Based on the progress in device and treatment development in this space and the increasing prevalence of peripheral artery disease, we are likely to continue to see new options come to market faster than long-term data can reasonably become available, and as this edition will detail, comparative data will always be sparse. With this in mind, we have invited experts with extensive trial and practical experiences to share their perspectives on device selection in situations when data conflict or are absent altogether. The authors provide an in-depth look at the nature of data, their sources, and the pitfalls of comparisons across trials and populations.
While working toward a perennially elusive consensus algorithm in the SFA, we must consider our current and future roles in generating the data needed to satisfy practitioners, payers, and last but not least, patients. The articles in this month’s edition are practical and candid in their assessments of current blind spots and needs. We hope these perspectives lead to lively discussion and ultimately action in developing increasingly meaningful data to further guide our patient-centered decisions.
Marianne Brodmann, MD
William A. Gray, MD
Guest Chief Medical Editors