Opinion on and Experience in Stent-Assisted Angioplasty at the Level of the Common Femoral Artery: Response to a Letter
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LETTER TO THE EDITOR
Opinion on and Experience in Stent-Assisted Angioplasty at the Level of the Common Femoral Artery: Response to a Letter to the Editor Hans Stricker1
Received: 15 June 2020 / Accepted: 22 June 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
We thank the editor for the opportunity to respond to the letter by Sheehan et al., who had several concerns about the results and the interpretation of our study [1]. Particularly, they mentioned issues about the high mortality of our patients, the lacking information about stent fracture, and the degree of calcification and of the severity of restenosis. Moreover, they criticized the protocol used to detect restenosis. Lastly, they wondered about the possible issues with potential accessibility of femoro-femoral crossover bypass to the stented profunda femoris when the superficial femoral artery (SFA) was occluded. Mortality is high in a population of patients with peripheral artery disease (PAD) [2], which is not only due to cardiovascular complications, but also to diseases that share the same risk factors such as smoking. In our series, 39% of the patients had died from cardiovascular cause, compared to 29% of patients who had died from cancer and chronic pulmonary disease (12/31 and 9/31 patients, respectively). Overall mortality in our study is in line with the figures published in the literature. In the Rotterdam study, 10-year mortality in patients with PAD was between 21 and 66% depending on a risk factor score [3], and Criqui found a 10-year mortality of 49% (32 of 67) in PAD patients [2] similar to our 44% (35 of 79). Mortality rate was 63.3% after 120 months (by Kaplan–Meier curves) in surgical patients after common femoral endarterectomy [4], which is similar to our findings (60% after 120 months, [1]). As we pointed out in our paper, the high mortality rate
& Hans Stricker [email protected] 1
relativizes the importance of patency rates over a very long follow-up period. We are aware of the limitation that stent fractures were not looked after systematically. However, if it is true that stent fractures will invariably lead to restenosis, it may be sufficient to look for symptomatic restenosis from a practical point of view, as asymptomatic stent fractures would probably not have been treated. The lower limb arterial calcium (LLAC) score was proposed by Chowdhury et al. [5]. It would have been interesting to analyse our patients by such a score, but these data are hardly obtainable in our series beginning in 1995. A typical patient presents with very localized eccentric cauliflower-like calcification in the common femoral artery (CFA) with high-grade stenosis (Fig. 1) and relatively undamaged proximal and distal arteries. The severity of the treated stenosis was hemodynamically important (we did not break down the degree of the stenosis to numbers), as demonstrated by the highly significant improvement of the post-interventional ABI.
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