Primary Stenting in Femoropopliteal Occlusive Disease - What Is the Appropriate Role?

Endovascular treatment of femoropopliteal occlusive disease is challenging and often limited by its unique anatomic, hemodynamic and biomechanical constraints. Despite technical improvement, percutaneous transluminal angioplasty alone is not adequate to provide satisfactory long-term patency. Several randomized controlled trials have shown that primary nitinol stenting can provide a better short-term radiological patency in intermediate lesion, but the results were often limited by intrinsic stent complications, particularly in-stent restenosis. Solutions to long lesions have been more elusive. To date, many novel technologies have been developed with a goal of improving stent design for this specific environment. Interwoven stents are made to provide a higher radial strength and kink resistance. Covered stents are designed to prevent the ingrowth of intimal hyperplasia, which is the main cause of restenosis in bare metal stent. Drug-eluting stents have shown improved patency in clinical trials. Bioabsorbable stents, combining biological agents and mechanical scaffold, provide temporary vascular support while reducing implant-related vascular inflammation in the long term. New developments in balloon angioplasty, such as drug elution, provide a challenge to stenting in this arena. Although these technologies look promising, a uniform reporting system and large-scale comparative studies with longer follow-up are needed to evaluate their clinical effectiveness in the future.