LAUSR

Ever since the advent of the endovascular revolution, there has been a drive to prove endovascular revascularization to be as good as or better than its surgical counterpart. Countless manuscripts have been published on this topic, and yet we are still far from an evidence-based consensus of what type of revascularization works best for whom. Ohki and colleagues “threw down another gauntlet” by evaluating short-term outcomes in a cohort of mostly claudicants with long superficial femoral artery (SFA) lesions treated with self-expanding stent grafts. The “invasiveness” of stent grafting was compared with data derived from historical controls treated with prosthetic femoral above-knee popliteal bypass. Their prospective, multicenter, Japanese registry included 100 patients with intermittent claudication who were judged to be candidates for surgical bypass. To be included in the registry, patients had to have had adequate aortoiliac inflow, no previous SFA stenting, distal SFA diameter of 4 to 7.5 mm, and at least one patent tibial artery. Patients were treated with GORE Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) stent grafts, observed for 12 months, and compared with 68 consecutive, contemporaneous patients treated with prosthetic bypass. In the stent graft cohort, the median SFA lesion length was 22 cm, and the majority of lesions were classified as TransAtlantic InterSociety Consensus II type C. The median stent graft coverage length was 25 mm, and technical success was excellent. Primary assisted patency rate and freedom from target lesion revascularization at 12 months were 95.9% and 94.9%. During follow-up, there were five graft occlusions free of acute limb ischemia. In comparison with the historical surgical controls, the endovascular cohort had less use of general anesthesia, shorter procedural times, less blood loss, less need for transfusion, and shorter length of stay. The authors concluded that their results support the use of stent grafts as an alternative to femoral above-knee popliteal bypass. Although these results add to the growing literature that supports short-term outcomes of the Viabahn stent graft in the SFA, they do not clarify how to best treat