We had an opportunity to revisit and discuss at some length the so-called "No-Stent Policy" (in PAD lower extremity intervention) at the recent excellent VERVE Symposium in Sydney, Australia. Such “policy” relates basically to the consensus of sorts that has existed among interventionalists for many years regarding the undesirable potential consequences and implications of placing a permanent metallic implant in the common femoral artery (CFA) in the groin, and in the popliteal artery in the knee region.
The presentations and subsequent discussions focused on the topic in a manner that considered these 2 regions separately:
- For the popliteal artery: it was noted that recent advances in endovascular stent technologies have made it possible to stent this vessel in and about the knee with little fear of subsequent device kink or dislocations or fractures, and with a realistic new expectation of long-term patency. This applies particularly to the remarkable Supera stent (Abbott Vascular) that has been reported to perform well and achieve high rates of sustained patency in some of the most complex anatomical conditions, including heavily calcified long lesions in the popliteal artery (and beyond). And with a near-zero fracture rate!
Other new-generations stents can be expected to offer superior performance as well, especially those designed to induce swirling blood flow across them, such as the Bio-Mimetics device (no yet available). For all these reasons, it seems reasonable today to alter the time-honored policy and proceed with stenting in the knee region (using the Supera stent and the like) when dealing with severe complex atherosclerotic disease and a clinical imperative for revascularization. Atherectomy offers some good device choices as well.
- For the common femoral artery in the groin, a preponderance of experts agreed that open surgical reconstruction (mainly, endarterectomy and patch angioplasty) remains an appealing and superior treatment option because of its relative simplicity (often done under local anesthesia, and through a short incision) and minimally invasive nature (as far as surgery goes), and its proven track record of performance and durability. Furthermore, it was noted that invading this region with placement of a metal stent across the CFA carries two highly undesirable implications: encroachment on the profunda femoris artery, and precluding or complicating trans-femoral access for a subsequent cardiac or vascular intervention – a not unlikely scenario in the majority such patients.
For all these reasons, it was agreed the no-stent policy should remain firmly in place for the CFA for the time being, and this is not likely to change any time soon. This represents by the way one of only two exceptions to the all-endo approach to atherosclerotic arterial occlusive disease today, the other one being carotid endarterectomy where open surgery continues to dominate.
That said, there are exceptional situations and cases where an endovascular approach and even stenting for some CFA lesions might be reasonable and offer a good expectation of immediate and mid-term success, so I would keep the endo option on the table but to be used judiciously and only infrequently.