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BackTable / VI / Podcast / Episode #181

Surgical vs. Endovascular Management of CFA Disease

with Dr. Mazin Foteh and Dr. Sabeen Dhand

Vascular Surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for calcified common femoral artery (CFA) disease, including discussing the pros and cons of an endovascular vs surgical approach.

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Surgical vs. Endovascular Management of CFA Disease with Dr. Mazin Foteh and Dr. Sabeen Dhand on the BackTable VI Podcast)
Ep 181 Surgical vs. Endovascular Management of CFA Disease with Dr. Mazin Foteh and Dr. Sabeen Dhand
00:00 / 01:04

BackTable, LLC (Producer). (2022, January 24). Ep. 181 – Surgical vs. Endovascular Management of CFA Disease [Audio podcast]. Retrieved from https://www.backtable.com

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Podcast Contributors

Dr. Mazin Foteh discusses Surgical vs. Endovascular Management of CFA Disease on the BackTable 181 Podcast

Dr. Mazin Foteh

Dr. Mazin Foteh is a practicing vascular surgeon in Austin, Texas.

Dr. Sabeen Dhand discusses Surgical vs. Endovascular Management of CFA Disease on the BackTable 181 Podcast

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Synopsis

In this episode, vascular surgeon Dr. Mazin Foteh and our host Dr. Sabeen Dhand consider various factors that can influence the choice of treatment methods for common femoral artery (CFA) disease.

To start, Dr. Foteh describes risk factors of common femoral disease, such as smoking, renal failure, and diabetes. He notes that CFA lesions are usually calcified and homogenous because they are composed of layers of calcium, lipid, and platelets deposited in fibrin sheaths. He further distinguishes between partially occluded and fully occluded CFA lesions.

Dr. Foteh reviews key tips to minimize complications during an open endarterectomy. To maximize exposure, he recommends making a longitudinal incision rather than a medial groin incision. Before closing, he also ensures that he checks 3-4 cm proximal and distal to the CFA and stents the external iliac artery if needed. Dr. Foteh opts for general anesthesia over local anesthesia, in case of unforeseen complications.

With an endovascular approach, Dr. Foteh finds that shock wave lithotripsy has been most effective at cracking calcium, changing vessel compliance, and ultimately increasing luminal gain. He uses this technique first, examines the results, and then uses a drug-coated balloon or stent as needed.

Resources

Clinical Trial Investigating the Efficacy of the Supera Peripheral Stent System for the Treatment of the Common Femoral Artery: https://clinicaltrials.gov/ct2/show/NCT02804113

Transcript Preview

[Dr. Mazin Foteh]
Yes. It could be quite a challenge. Truthfully, Sabeen, there have been many scenarios where I've done common femoral artery occlusions, I've treated it with lithotripsy, the vessel has stayed open, and maybe one to two years down the road, there might be a restenosis and I have to do a common femoral endarterectomy. Then when I get him to the OR, the vessel is still open. Still open.

[Dr. Sabeen Dhand]
That's great.

[Dr. Mazin Foteh]
To me, that's a testament to a great end result.

[Dr. Sabeen Dhand]
Without the open incision and all that. We're in the right direction compared to 10 years ago.

[Dr. Mazin Foteh]
Yes. On occasion, you're treating somebody for rest pain or you're treating somebody for tissue loss. The only thing you find is a common femoral artery occlusion. You cross that occlusion and you lithotripsy it, the vessel stays open. The patient's rest pain disappears or the gangrene heals. If they're a young patient, maybe you send them to your surgeon and say, "Hey, this worked. I'm worried it's not going to last a long time. Could you do a preemptive endarterectomy for him?" I think that's a great scenario. I really do. I think this tool gives you the option of not having to back out either. If you encounter that in a tough scenario, now you at least have an option of treating somebody.

[Dr. Sabeen Dhand]
Exactly. That's true. That's good. You still can do something. Then it's really important that-- That was one of my big questions, do I burn a bridge or compromise a surgery after if I'm doing something like this? In your experience, you don't, and that's huge. That's a huge take-home point.

[Dr. Mazin Foteh]
Yes. I think one other point we should make from that is that, if you're an interventional radiologist or if you're a cardiologist, don't let anybody tell you that that's going to happen either. I know you can remember this, five years ago when we started getting really aggressive with tibials, the first thing all the surgeons said was, "Oh, they're going to burn all of our bypass bridges. We're not going to be able to do a bypass now." Yes, if you stent the entire vessel, you're not going to be able to do a bypass. If you go in there and you balloon a PT or an AT, you're going to be able to bypass the patient.

Truthfully, as somebody who was very aggressive, I had some of my partners tell me, when I got aggressive with tibials, "Hey, you're going to create a lot of bypasses for us." I said, "No, I don't think so. Maybe you're right, but I don't think so." Luckily, that hasn't been the case.

[Dr. Sabeen Dhand]
That's great.

[Dr. Mazin Foteh]
That really has not been the case. The same is true for the common femoral artery. You can balloon it, you can do atherectomy, you can do lithotripsy. The only thing I would say is, right now in a young patient, if you can avoid it, don't stent it. That's all I'm saying.

Dr. Foteh is a paid consultant for Shockwave Medical and opinions expressed are those of the speaker and not necessarily those of Shockwave Medical.

In the United States: Rx only.

Indications for Use—The Shockwave Medical Intravascular Lithotripsy (IVL) System is intended for lithotripsy-enhanced balloon dilatation of lesions, including calcified lesions, in the peripheral vasculature, including the iliac, femoral, ilio-femoral, popliteal, infra-popliteal, and renal arteries. Not for use in the coronary, carotid or cerebral vasculature.

Contraindications—Do not use if unable to pass 0.014″ (M5, M5+, S4, E8) or 0.018″ (L6) guidewire across the lesion-Not intended for treatment of in-stent restenosis or in coronary, carotid, or cerebrovascular arteries.

Warnings—Only to be used by physicians who are familiar with interventional vascular procedures—Physicians must be trained prior to use of the device—Use the generator in accordance with recommended settings as stated in the Operator’s Manual.

Precautions—use only the recommended balloon inflation medium—Appropriate anticoagulant therapy should be administered by the physician—Decision regarding use of distal protection should be made based on physician assessment of treatment lesion morphology.

Adverse effects–Possible adverse effects consistent with standard angioplasty include–Access site complications–Allergy to contrast or blood thinner–Arterial bypass surgery—Bleeding complications—Death—Fracture of guidewire or device—Hypertension/Hypotension—Infection/sepsis—Placement of a stent—renal failure—Shock/pulmonary edema—target vessel stenosis or occlusion—Vascular complications. Risks unique to the device and its use—Allergy to catheter material(s)— Device malfunction or failure—Excess heat at target site.

Prior to use, please reference the Instructions for Use for more information on indications, contraindications, warnings, precautions and adverse events. www.shockwavemedical.com/ifu

Please contact your local Shockwave representative for specific country availability.

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Endarterectomy for CFA Disease: Indications, Techniques & Risk Reduction

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Topics

Arterial Revascularization Procedure Prep
Atherectomy Procedure Prep
Common Femoral Artery (CFA) Disease Condition Overview
Critical Limb Ischemia (CLI) Condition Overview
Endarterectomy Procedure Prep
Intravascular Lithotripsy Procedure Prep

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