Role of total endoluminal superficial femoral artery bypass.

The superficial femoral artery (SFA) is a common site of atherosclerosis and peripheral vascular disease. Many times this disease can be treated with medical management alone; however, as the disease process advances, it may require further action. Therapies for occlusive disease include lifestyle modification, pharmacologic agents, and revascularization by either a percutaneous or an open surgical approach. Surgical bypass using autogenous vein (the "gold standard") or synthetic graft has been the traditional treatment for severe SFA disease, but the use of minimally invasive endovascular techniques, which entail less morbidity than the traditional surgical approach, has increased markedly in recent years. The most commonly employed endovascular procedure is percutaneous transluminal angioplasty (PTA). Self-expanding bare metal stents and, more recently, drug-eluting nitinol stents have been found to offer improved patency compared with PTA alone, especially as lesion length increases. Research on these devices is ongoing, with investigations addressing such concerns as in-stent restenosis, stent fracture, and long-term patency. Another alternative for treatment, especially for longer SFA lesions, is total endoluminal SFA bypass via percutaneous access using covered stent-grafts. A long-standing debate in the medical community concerns the role of a covered stent-graft as opposed to bare metal stents and other available modalities. In a report on a randomized comparison between covered Viabahn® (WL Gore & Associates, Flagstaff, AZ, USA) stent-grafts and prosthetic bypass in the treatment of SFA disease, we recommended that total endoluminal SFA bypass is most appropriately used for long lesions (>10 cm), whereas PTA and bare nitinol stenting are probably most suitable for treating short (3-5 cm) and medium-length (<10 cm) lesions, respectively.