Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 12-02: Occlusive Disease: Femoral & Popliteal Arteries + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Cramping pain or tiredness in the calf with exercise Reduced popliteal and pedal pulses Foot pain at rest, relieved by dependency Foot gangrene or ischemic ulcers +++ General Considerations ++ The superficial femoral artery is the peripheral artery most commonly occluded by atherosclerosis The disease frequently occurs where the superficial femoral artery passes through the abductor magnus tendon in the distal thigh (Hunter canal) The common femoral artery and the popliteal artery are less commonly diseased, but lesions in these vessels are debilitating, resulting in short-distance claudication +++ Demographics ++ Atherosclerosis of the femoral-popliteal segment usually Occurs about a decade after the development of aortoiliac disease Has an even distribution between males and females Affects black and Hispanic patients commonly + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Intermittent claudication is confined to the calf Claudication at about 2–4 blocks when superficial femoral artery is occluded at the abductor canal and good collateral vessels are maintained from profunda femoris Concomitant disease of the profunda femoris or the popliteal artery may trigger symptoms at much shorter distances Dependent rubor of the foot with blanching on elevation may be present with short-distance claudication Chronic low blood flow states cause atrophic changes in the lower leg and foot with Loss of hair Thinning of the skin and subcutaneous tissues Disuse atrophy of the muscles With segmental occlusive disease of the superficial femoral artery, the common femoral pulsation is normal, but the popliteal and pedal pulses are reduced Popliteal and pedal pulses are reduced +++ Differential Diagnosis ++ Occlusive disease of the iliac arteries Lumbar spinal stenosis + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ Duplex ultrasonography, CT angiography, or magnetic resonance angiography All adequately show the anatomic location of the obstructive lesions These studies are only done if revascularization is planned +++ Diagnostic Procedures ++ The ankle-brachial index (ABI) Values < 0.9 are diagnostic of PAD Levels below 0.4 suggest chronic limb-threatening ischemia Readings depend on arterial compression Can be misleading since the vessels may be calcified in diabetes mellitus, chronic kidney disease, and the elderly The toe brachial index (TBI) Usually reliable; done in those cases where vessels may be calcified Value < 0.7 considered diagnostic of PAD Pulse volume recordings with cuffs placed at the high thigh, mid thigh, calf, and ankle will delineate the levels of obstruction with reduced pressures and blunted wave-forms + Treatment Download Section PDF Listen +++ ++ Conservative management Cornerstone of therapy Includes risk factor reduction, medical optimization (with high-dose statin), and exercise treatment Cilostazol, 100 mg orally twice daily, may improve intermittent claudication symptoms +++ Surgery ++ Indications Claudication that is progressive, incapacitating or interferes significantly with essential daily activities Presence of ischemic rest pain Ischemic ulcers threaten the foot Femoral-popliteal bypass with autologous saphenous vein is most effective and durable treatment for lesions of the superficial femoral artery Synthetic material, polytetrafluoroethylene (PTFE) can be used but these grafts do not have the durability of vein bypass Removal of the atherosclerotic plaque is now limited to the lesions of the common femoral and profunda femoris artery where bypass grafts and endovascular techniques have no role Endovascular techniques such as angioplasty and stenting May be effective for lesions of the superficial femoral artery These techniques have lower morbidity than bypass but also have a lower rate of success and durability Most effective for lesions that are < 10 cm long and in patients who are undergoing aggressive risk factor modification Paclitaxel-eluting stents or paclitaxel-coated balloons Offer modest improvement over bare metal stents and non-coated balloons Meta-analyses of clinical trial data have shown increased mortality 3–5 years after treatment with paclitaxel devices Although they remain on the market, the US FDA has recommended judicious use of the devices However, the success of local drug delivery in peripheral arteries is not as robust as that in the coronary arteries + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Ultrasound surveillance after all interventions so that recurrent narrowing can be treated promptly +++ Complications ++ Wound infection or seroma can occur in as many as 10–15% of cases Myocardial infarction rates after open surgery are 5–10%, with a 1–4% mortality Complication rates of endovascular therapy are 1–5% +++ Prognosis ++ Excellent for motivated patients with isolated superficial femoral artery disease Patency rate of bypass grafts of the femoral artery, superficial femoral artery, and popliteal artery is 65–70% at 3 years Patency rate of angioplasty is < 50% at 3 years 5-year mortality among patients with lower extremity disease associated with coronary disease is about 50% The 1-year patency rate for Balloon angioplasty: 50% Drug-coated balloons: 70% Stents: 80% By 3 years, the patency rates are significantly worse for all three techniques and reintervention for restenosis is common Because of the extensive atherosclerotic disease, including associated coronary lesions, 5-year survival with lower extremity PAD is 70% and decreases to 50% when there is involvement of the tibial arteries However, with aggressive risk factor modification, substantial improvement in longevity has been reported +++ When to Refer ++ Patients with progressive symptoms, short distance claudication, rest pain, or any ulceration should be referred to a peripheral vascular specialist + References Download Section PDF Listen +++ + +Dake MD et al; Zilver PTX Investigators. Durable clinical effectiveness with paclitaxel-eluting stents in the femoropopliteal artery: 5-year results of the Zilver PTX randomized trial Circulation. 2016 Apr 12;133(15):1472–83. [PubMed: 26969758] + +Hiramoto JS et al. Interventions for lower extremity peripheral artery disease. Nat Rev Cardiol. 2018 Jun;15(6):332–50. [PubMed: 29679023] + +Katsanos K et al. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2018 Dec 18;7(24):e011245. [PubMed: 30561254] + +Laird JR et al; IN PACT SFA Trial Investigators. Durability of treatment effect using a drug-coated balloon for femoropopliteal lesions: 24-month results of IN. PACT SFA. J Am Coll Cardiol. 2015 Dec 1;66(21):2329–38. [PubMed: 26476467] + +Rocha-Singh KJ et al; VIVA Physicians, Inc. Patient-level meta-analysis of 999 claudicants undergoing primary femoropopliteal nitinol stent implantation. Catheter Cardiovasc Interv. 2017 Jun 1;89(7):1250–6. [PubMed: 28303688] + +Rosenfield K et al; LEVANT 2 Investigators. Trial of a paclitaxel-coated balloon for femoropopliteal artery disease. N Engl J Med. 2015 Jul 9;373(2):145–53. [PubMed: 26106946]