LAUSR

To the Editor, We read with interest the article “Stent-Assisted Angioplasty (SAA) at the Level of the Common Femoral Artery Bifurcation: Long-Term Outcomes” by Stricker et al. [1] published in January 2020 as it has potential implications for practice. The study concludes that stentassisted angioplasty of the common femoral artery (CFA) results in high initial success with low peri-procedural complication rate and a moderate restenosis rate on followup. We wish to contribute to the discussion and our experiences surrounding the use of stents at this level. Common femoral endarterectomy (CFE) has been the gold standard for treatment of CFA lesions over endovascular treatment, due to its long-term patency, ability for reintervention and concomitant access to the profunda femoris artery. However, there is no doubt that CFE has a higher complication rate than the endovascular approach. We do acknowledge there has been recent evidence to suggest that there is no statistically significant difference in the recurrence of stenosis as per the randomized control trial—TECCO (Endovascular Versus Open Repair of the Common Femoral Artery) [2]. However, randomized patient numbers were small in the latter study (61 vs 59, surgery vs stenting) and only CFA stenoses were treated. Moreover, guidelines still recommend open repair (European society of Cardiology) [3]. In the paper by Stricker et al., there are a number of issues that cloud the results mentioned. These include the high patient mortality during follow-up (44.3%), the majority of patients had CFA stenosis (69/79) rather than occlusions, there is no quantification of the degree of calcification in the CFA, stent fractures were not recorded (given the location of stenting at the level of the hip joint and risk of stent occlusion post-fracture, it would seem a pertinent parameter to include). The stent types used varied and technologies have improved over the study period, and our experience particularly with the earlier stents had a not insignificant fracture and occlusion rate and the true number of patent stents is unknown. Furthermore, although restenosis was seen in 25% (23/ 94) of the treated limbs over a median of 53 months, there is no breakdown of these limbs in terms of the percentage severity of vessel stenosis. The surveillance protocol used to detect restenosis was based on ankle–brachial pressure index (ABI) measurement with patients only proceeding to duplex ultrasound “if there was anamnestic or clinical suspicion of restenosis”; therefore, the authors are equating the lack of a drop of ABI to a patent stent. The high 1–5year patency rate (96–78%) is therefore suspect without a breakdown of the number of limbs imaged with duplex, MRA or CTA. Lastly, the practice of stenting into the profunda femoris when the SFA was occluded (26 patients) is not without risk in our opinion. Potentially, the latter practice could hinder later femoral to profunda crossover bypass procedures, if required. We believe the jury is still out as to whether endovascular stents can achieve the same long-term patency and limb salvage rates for CFA disease compared with CFE based on the current evidence. Whether customized newer generation nitinol stents with “swirling flow” geometry or & Mark Sheehan [email protected]