Percutaneous endovascular treatment of long femoro-popliteal arterial occlusion : A review of the literature

Today the problem about the best way to manage peripheral arterial disease (PAD) remains unresolved. Infrainguinal bypass has been the gold standard treatment for patients presenting with critical limb ischemia, defined as ischemic chronic rest pain, ulcers, or tissue loss. Critical limb occlusions (CTOs) of the femoro-popliteal and trifurcation vessels are classified as TASC II type C and D lesions where surgical revascularization is traditionally the treatment of choice. Particularly vein bypass remains the "optimum" against which, any infrainguinal arterial reconstruction technique for superficial femoral artery (SFA) occlusion, should challenge. Great progress has been made in the endovascular treatment of the SFA, that has led to a recent development of subintimal technique, re-entry devices, a more aggressive approach for treating peripheral artery disease and more flexible, long nitinol stents. Thus the advent of new endovascular techniques and devices has changed the landscape of vascular intervention allowing these lesions to be treated by endovascular means with rates of more than 90% for TASC II C and D lesions. If done appropriately, endovascular revascularization of aortoiliac and femoro-popliteal CTOs, successful or not, should not prevent the ability to perform subsequent surgical revascularization. Many trials and review have been analyzed for every technique described in this paper with the aim to analyze the current status of endovascular technique trying to clarify which could be the best endovascular way to treat this class of lesions.