BackTable / VI / Podcast / Transcript #181

Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Understanding Common Femoral Artery Disease

(2) When to Treat Common Femoral Artery Disease

(3) Preventing Restenosis after Endarterectomy

(4) Endarterectomy Surgical Pearls

(5) The Role of Anesthesia in Common Femoral Endarterectomy

(6) Reevaluating Endovascular Intervention for Common Femoral Artery Disease

(7) Addressing Severe CFA Calcifications with Lithotripsy

(8) Impact of Endovascular Lithotripsy on Future Surgical Pathways

(9) Protecting the Profunda: Managing Risks in Common Femoral Interventions

(10) Emerging Trials & Multimodality Approaches in Common Femoral Artery Treatment

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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

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[Dr. Sabeen Dhand]
I'm Sabeen Dhand, an IR from LA, and I'd like to welcome Dr. Mazin Foteh from Cardiothoracic and Vascular Surgeons in Austin, Texas. Welcome, Mazin.

[Dr. Mazin Foteh]
Sabeen, thank you for having me this afternoon. I'm glad to be here, and I'm very excited to talk about this exciting new space in the arterial system that has always sort of been off-limits to us. Hopefully we can dive deep into the topic and talk about some new technologies that we're getting to use in that space, but I'm just so excited to be here today.

[Dr. Sabeen Dhand]
Yes, no, thank you. Thank you so much for taking the time. Honestly, we're going to be talking about standard and non-standard approaches to common femoral disease. It was important to me and it was important to us to select someone who's well-versed in both open and endo, because someone talking who only does endo or someone only who does open, it's inherently going to be really biased. I'm super excited to pick your brain and really know the benefits of both and see where things are going in the future.

[Dr. Mazin Foteh]
Absolutely.

[Dr. Sabeen Dhand]
Tell us a little bit more about, were you always in Austin? What made you go over there to an awesome city?

[Dr. Mazin Foteh]
Yes. I did my fellowship training at UT Southwestern in Dallas. I actually did my general surgery residency there as well and then stayed on for vascular. In total, I guess I was there for seven years.

[Dr. Sabeen Dhand]
You grew up in Texas?

[Dr. Mazin Foteh]
Yes, I grew up in Texas, grew up in Houston, actually, and all my family still lives there, interestingly enough. I'm the only person in my family who doesn't live in Houston.

[Dr. Sabeen Dhand]
Oh, really? You made the check out, check out to Austin.

[Dr. Mazin Foteh]
Austin's like a suburb of Houston at this point, but to your point, it's a great city. I wasn't particularly looking for Austin when I was searching for jobs, but I got a phone call one day from one of the partners in the group. They actually called my program director, and they were looking for somebody. I was fortunate enough to train at Southwestern, where we had two really aggressive endo guys, Carlos Timaran and Frank Arko. I learned so much from them. They were actually looking for somebody who had a lot of endovascular experience.

I came down here after a difficult case, actually, and interviewed and it was great. I've been here now 10 years. I'm just tickled to the-- as can be, this has been a great job for me. I have the greatest partners and, I feel, one of the best cities in the United States to work in. I'm very happy.

[Dr. Sabeen Dhand]
Do you guys associate with a lot of hospitals, or how does-- 20 plus surgeons is a lot. Is it a big surgical center or how does it work?

[Dr. Mazin Foteh]
Yes. We are a private practice and we work in both hospital systems here in Austin. One is an Ascension system and the other is HCA. We work in basically three settings, in-hospital, inpatient hospital, outpatient hospital, and then we have OBLs is where we do cases. All of us rotate through all the different hospitals here. Right now we're covering nine facilities. It's very, very busy. Luckily, we have great partnerships with the hospitals. We get along very well. I think we get along pretty well with all the subspecialties also. There's no turf wars, which I think is unique about this city.

We don't go after other subspecialties who do peripheral work. I've heard of that happening in other locations. We tend to be pretty friendly, We all have complications, and Sabeen, sometimes I'm going to need your help and sometimes you're going to need my help.

[Dr. Sabeen Dhand]
Always goes both ways.

[Dr. Mazin Foteh]
It always goes both ways. Behind closed doors, you'll probably complain about it, but when it comes down to patient care, at the end of the day, you just got to take care of the patients.

[Dr. Sabeen Dhand]
Totally.

[Dr. Mazin Foteh]
We've really taken that approach and it's been fortunate for us, I would say.

[Dr. Sabeen Dhand]
Yes. No, that's really great. You obviously have such a big vascular practice. How much is it, would you say, broken down by open or endo? You personally.

[Dr. Mazin Foteh]
Yes. I've been in a transition since I've been here. When I came in, I was the new guy, and the new guy is always doing the most minimally invasive thing that you can do, and that was endo. Quite honestly, at one point in my practice, I was probably 90% endo. That was in all aspects. That included the aortic disease, carotids, peripheral vascular work. Then you learn over time what really works where.

I would say today that has shifted to where I'm probably still about 70% endo and 30% of my cases get done endovascularly or some hybrid-- Sorry, I should say that again. 70% endo, 30% open, and then there's some hybrid work that gets done as well. You just learn. You just learn what's going to work where. You have to be adept in both areas, and that way, we get to tailor care, and I really enjoy doing that.

[Dr. Sabeen Dhand]
What's awesome is, like you said, you tag team cases and you learn. The thing is you learn after training. I'm lucky to be within some awesome IRs and vascular surgeons here. I learned so much, even now, seven years after I've been done with training. You've learned probably plenty of things on the job.

[Dr. Mazin Foteh]
Oh, absolutely. I used to giggle a little bit when one of my mentors would say, "You know how I got so good at endo?" I said, "No." He said, "I used to actually go in and sit in the cardiology cath lab and watch them do STEMIs," and I was like, "No way." This guy had, an ego beyond egos. Truth be told, at the VA, when I was in Dallas, I did a little of that as well. There was two cardiologists there, but they were just fantastic. I learned micro wire and micro catheter skills watching those guys. Yes. It was great.

I encourage anybody who's listening to this podcast, don't think everything because you don't, you just don't. There's so much to be learned from IR, there's so much to be learned from cardiology, there's so much to be learned from neurointerventional. Take the time to sit back and watch when you have some downtime because it could help you one day.

(1) Understanding Common Femoral Artery Disease

[Dr. Sabeen Dhand]
Yes. Words of wisdom. Let's talk about our topic. Let's get at it. Acute common femoral disease. We're not even going to talk about, we know, all of us have been there, closure device injury or some hydrogenic injury, that's surgical. As far as the technique, we'll cover, but we're going to be talking about chronic disease. What type of patients, Mazin, do you see get pretty bad chronic common femoral disease? Is it the diabetics? Are it the smokers? Is there any type of pattern?

[Dr. Mazin Foteh]
Yes, I think there are some patterns here. Let's take out of the picture the folks who have had multiple access points in their common femoral arteries, and let's just focus on primary atherosclerosis and who presents with common femoral disease. Truly, it's smokers. Those are the folks who are going to get aortoiliac occlusive disease and common femoral disease.

On occasion, you might encounter your diabetics or your end-stage renal patients who have some common femoral disease, but in general, those folks are going to be free from atherosclerotic plaque and the common femoral distribution. It's usually younger patients, it's usually heavy smokers, and they typically get dense calcific disease in the common femoral artery. Those are the folks that we are commonly approaching.

[Dr. Sabeen Dhand]
Yes, that's what I was going to ask you. What's the morphology? Is it usually calcified? Is it atheromatous? What do you most commonly encounter in these smokers?

[Dr. Mazin Foteh]
Yes, so generally, less atheromatous and more calcified homogenous plaque or heterogeneous plaque in the common femoral artery. Typically speaking, when you open these vessels up to do an endarterectomy, you're not going to see the cauliflower appearance, dense calcified disease. It's usually layers and layers of calcium and lipid deposits and platelet deposits encased in a fibrin sheet.

Over time, as that lipid deposit and platelet deposit increases, luminal patency and luminal diameter tends to decrease over time. When we do endarterectomies, when it's completed, we have this nice, five to six centimeter long lesion. If you turned it on end and looked straight down the center, you got one to two millimeters of flow, typically speaking. Removing it, particularly in young patients, works really well.

As you know, the beauty of that is it's a pretty durable operation. Thinking back in the last 10 years, I actually can't think of a patient where I've had to go back and do a repeat intervention on a common femoral for a young patient as long as it was done well. I know it does happen, but nothing directly comes to mind. To get back to your question, it's just a different animal. It's not like what you see in tibial disease and it's certainly not what you see in the SFA. It's just a completely different animal.

[Dr. Sabeen Dhand]
Yes. No, I'm always amazed. As endovascular guys, we're so used to seeing what it looks like on ultrasound or maybe IVUS or CT, and I always get amazed. Just this last week, we did a cut-down approach for an EVAR with our vascular surgeon, and the common femorals, they were just so jacked. It was just so amazing to see what the artery-- It just looked like an artery, looked a little irregular. You can touch it and it just feels-- It doesn't feel like a rock. It just feels like this really firm vessel that's not normal. It's amazing to see it physically. It's way different than what you'd expect.

[Dr. Mazin Foteh]
Absolutely. Unfortunately, I think ultrasounds and CT scans sometimes are just really great suggestions. To your point, I was doing a case yesterday, actually, an EVAR on a patient, and we did it percutaneously. I was a little bit worried about the right side. Before continuing with the EVAR, I went up and over and took some pictures and I found a big 90% stenosis below my access point. I did all the right things. I went ahead and crossed it from the other side. I removed my sheath, I ballooned it, I took a picture after the sheath went back in and it looked beautiful. Despite all that, at the end of the [unintelligible 00:13:37], no flow.

Interestingly, when I do my EVARs, I always do them with [unintelligible 00:13:44], and within minutes of pulling the sheath, the tech reached out and said, "Hey, Dr. Foteh, I'm losing signals here." I immediately cut down, and God, it was just such a horrible vessel that you would have never appreciated on CT or ultrasound. Yes. It can definitely hide some snake within those thick walls. Yes.

[Dr. Sabeen Dhand]
Yes. Now, there's something we would do-- We'd almost see drive-by common femoral disease. Meaning, the patient has multi-station disease, SFA disease, tibial disease, those common femoral disease. A lot of times we just pass by it, endovascular, and treat the SFA and tibial, and we just see, "Okay, let's see if we even have to treat the CFA disease."

(2) When to Treat Common Femoral Artery Disease

[Dr. Sabeen Dhand]
The question I'm getting at here is, when do you have to treat common femoral disease? Because sometimes you treat all that and the patient gets better
.
[Dr. Mazin Foteh]
Yes, no, I've been there too myself. Oftentimes, for instance, if you have a tight iliac or a SFA occlusion, and even in the setting of common femoral disease, and you leave the common femoral alone, most people are going to be fine. I think where it's really critical for us to treat the common femoral are several scenarios. These are the ones that are coming immediately to mind. If at any point the profunda femoris artery is going to be compromised or is prone to being compromised because the common femoral disease is so significant, to me, it oftentimes means I should preemptively try to treat that common femoral.

If there is a bypass graft below the common femoral that is necessitating inflow, that's somebody, I think, that should be treated. If there's an SFA dent that you're worried potentially has the ability to go down if you don't treat it, I would definitely think about doing it as well. Then on the flip side, in the superior disease, if you do stent the iliacs or if you balloon the external, but you leave a 90% common femoral stenosis, that's not going to do anybody any good. It tends to be an underappreciated artery.

There have been many scenarios where the operation I will offer is just a common femoral artery endarterectomy in somebody who has multi-level disease. More often than not, especially for claudicants, that's what gets them better. You don't have to treat the SFA and you don't have to treat the tibials and they can go on and have productive lives. It's just something you should really focus on and take some time appreciating.

Now everybody's trying to switch their access points, going to tibial, going to radial, forgetting about the common femoral artery. There's this saying, I think it was Julius Caesar or one of those Roman kings, that, "Don't forget your dying king." The truth is, the common femoral artery, we should respect it. We've been using it for such a long time and we shouldn't let it go by the wayside, but we also need to understand you can't leave a lot of bad disease in there, it's going to pretend a bad outcome.

(3) Preventing Restenosis after Endarterectomy

[Dr. Sabeen Dhand]
Yes, exactly. The endarterectomy, the surgical approach to common femoral disease, you've already mentioned that durability. it's by far very durable. I know it hasn't happened to you, but what are things that do make it, you have a recurrent disease in the patch or whatnot? What are some things that can cause that?

[Dr. Mazin Foteh]
Yes. There's a number of things. One thing you mentioned is the patch. There are still people out there who don't patch common femorals after doing endarterectomy. It's similar to doing CEA. There are still people out there who just do endarterectomy and then primarily close the carotid artery. If you don't patch it, I think that puts you at risk for restenosis. There's also a subset of patients who I think have inflammatory atherosclerotic disease. Those folks, they tend to scar no matter what you do. Despite doing a clean endarterectomy and not leaving-

[Dr. Sabeen Dhand]
They'll scar.

[Dr. Mazin Foteh]
They'll scar down and you'll be back. Then I think the other thing is when you're doing your endarterectomy, it's important to leave some of the media behind when you're getting into the layers to remove the plaque. If you take it all the way down to the adventitia and you remove all of the media, I think that leaves a very, very hyperplastic tissue bed and puts you at risk for restenosis. It's important to make sure you stay in the right tissue planes as well.

[Dr. Sabeen Dhand]
How hard is that to do, to separate, when you're there, the intima versus media versus adventitia? Are you able to actually tell the different layers?

[Dr. Mazin Foteh]
Generally, yes. Generally, you're able to get into a well-defined plane and it works out well for you to be able to do that. There are scenarios where the disease is so bad or it's exophytic calcium that embeds itself, even into the adventitia, that you just simply can't make a good tissue plane. Those are the folks that I think that instead of patching, you end up doing iliofemoral bypasses as opposed to doing endarterectomies.

It's an operation, I think, that doesn't get a lot of credit. People think it's just so easy to do and the recovery is so easy, but I think we also underestimate the complications that occur with that surgery. There was a huge NISQIP paper that came out back in 2008 looking at 75,000 endarterectomies that were done over a 10-year period. The readmission rate for that procedure was 15%, the complication rates were as high as 20% to 30%.

Typically speaking, these patients, pretty routinely will come back either with lymphoceles, they'll come back with groin incisions that are broken down, they'll come back with hematomas, chronic pain, and readmissions [crosstalk] hospital.

[Dr. Sabeen Dhand]
It's not [crosstalk] it's not completely-- [crosstalk]

[Dr. Mazin Foteh]
No, not by any means. In fact, that paper, actually, that population did have a mortality rate, a perioperative mortality rate of about 1% to 2%. Although rare, it's not without its complications.

[Dr. Sabeen Dhand]
Yes, absolutely. 75,000 is a big number, so you're going to find stuff. It's important to know that these type of procedures, that they're not as easy as sometimes some people may say they are.

(4) Endarterectomy Surgical Pearls

[Dr. Sabeen Dhand]
What about in your technique, and we won't go into in all techniques of what do you exactly do, but do you do anything other differently? You mentioned that you patch all of yours and you go to the media, but anything else you particularly do that makes your endarterectomy approach pretty successful?

[Dr. Mazin Foteh]
Yes. First off, you're going to run into surgeons out there who like to either do a longitudinal incision versus a medial groin crease incision. Really, for an endarterectomy, I think a medial groin incision doesn't really allow you to expose everything very nicely. I always do it longitudinally. I always go out very far on the secondary and tertiary branches of the profunda femoris. I always go about 3cm or 4cm into the SFA with my endarterectomy, and I never leave anything behind in the external iliac.

In fact, if I'm not able to reach it from my surgical approach, that patient more often than not is going to get an external iliac stent, just to ensure I leave no disease behind. Taking that extra time and ensuring that 3cm to 4cm proximal and 3cm to 4cm distal to your common femoral, the arteries are nice and clean, you're not leaving dissection planes behind, is key to really having a great outcome for those folks.

[Dr. Sabeen Dhand]
Yes, I can see now why you have such a good endarterectomy result, because you're definitely putting more into it than I've seen, doing the proximal 3cm of SFA. That's a lot more dissection. I've been there in these cases, where the vascular surgeon is dissecting, and yes, you can do a lot more, but it takes a lot more time.

[Dr. Mazin Foteh]
Definitely.

[Dr. Sabeen Dhand]
Dissecting three branches of the profunda, that's a lot.

[Dr. Mazin Foteh]
It gets to be a lot, but truthfully, even if you have to use two patches and sew them together, it's the right thing to do. It improves outcomes, and the patients will love you for it, is what I can tell you.

(5) The Role of Anesthesia in Common Femoral Endarterectomy

[Dr. Sabeen Dhand]
Now, there's a lot of people who-- I'm sure you do most of these under general anesthesia. Sometimes we see some claims as far as like, oh, these procedures can be done under local or whatnot. Is that a common occurrence, doing it under local, or is it pretty much all always under heavy sedation, MAC, or general?

[Dr. Mazin Foteh]
Yes, I think it's definitely something that gets talked about, doing it under less severe anesthesia is what I would say. In the 10 years that I've been in this practice, in my fellowship, in my general surgery training, I never saw a common femoral endarterectomy get done under local. The closest thing to a less than general anesthesia was a couple of MAC cases, where the patient got an LMA, but for the most part, these can be fraught with complications, too.

Sometimes getting control can be very difficult, and sometimes there's a significant amount of blood loss. I think it's a nice academic discussion to talk about doing under local, but when the rubber hits the road, very few of these cases actually get done at a local.

[Dr. Sabeen Dhand]
Yes, you need them to be asleep. I'm actually very impressed with the anesthesiologists. They can put anyone to sleep. The whole thing about all this-

[Dr. Mazin Foteh]
These days.

[Dr. Sabeen Dhand]
-yes, they're so good. A patient can have an EF of 15, and they're like, "Okay, it's fine, we'll handle it." [laughs]

[Dr. Mazin Foteh]
Yes, they make our lives really easy, and to your point, even folks with horrible COPD and on home oxygen, these anesthesiologists these days do such a good job. Mine have been excellent. I feel comfortable putting most people to sleep.

[Dr. Sabeen Dhand]
Yes, exactly. Your anesthesiologist is so used to your vasculopath patients that cardiac and all this other stuff is easy chip shots for them, so it's lucky we have anesthesiologists like this. When I see that argument of online, on social media, sometimes like a endovascular person might say, "Oh, we did it this way because the patient couldn't tolerate anesthesia," I'm like, yes, maybe shop around for some anesthesiologists and do what's best for the patient, whether it's open or surgical.

(6) Reevaluating Endovascular Intervention for Common Femoral Artery Disease

[Dr. Sabeen Dhand]
On that, let's switch gears and talk about the endo approach. Should we stop now? Is there validity to endovascular approach to CFA disease? Should we stop, or do you think there's validity in that?

[Dr. Mazin Foteh]
No. First of all, this is a topic that's very important to me. I know it's a topic that's very important to you, and the common femoral artery has always been the no-man's zone for endovascular intervention, and we've, over the years, have tried everything, from cryoplasty to atherectomy to drug-coated balloons to stenting. You name it, we've tried it, and I've laid, and I know we're going to get into it, but lithotripsy as well.

Today, there really hasn't been a great, useful tool to address calcific disease. Not one that can really affect the entire calcific lesion. Now, some of the atherectomy devices out there have the ability to get into the intimal calcium. Some can even because microfracturation in the medial layer, but none of them have the ability to get into the deeper layers of the calcium, 4 and even 6 millimeters deep, in order to have a great effect on the vessel.

Prior to the last couple of years, I think you included, just have been a little bit disappointed with the outcomes from common femoral and intervention. We didn't do it for a long time. Today, though, I think the tide is shifting. I think we now have some tools out there that seem to be much more effective for that particular artery and are performing much better over time, and I think the avenue for endovascular approaches are getting better. Some things that I think have improved as well is having different alternative access points has made it a little bit easier for us to do.

[Dr. Sabeen Dhand]
That's true. You don't have to stick to common femoral now.

[Dr. Mazin Foteh]
Yes, you can avoid it, so it makes it a lot easier for us to be able to treat these folks. I guess to answer your question, if you asked me 10 years ago, I would have told you, "Absolutely not, common femoral endarterectomy is the way to go," but for the past two years, I think my mindset has changed a little bit.

(7) Addressing Severe CFA Calcifications with Lithotripsy

[Dr. Sabeen Dhand]
Let's talk about the-- There's two types of CFA chronic disease, something that's still open. Now, you mentioned that nasty disease with a 2 millimeter open lumen or a total occlusion, but how about this nasty disease? What are some of the tools now that you can use, as long as the CFA is open, to help you with this chunky calcium lipid layer plaque?

[Dr. Mazin Foteh]
The tool that I've been using of late, and I know you're aware of it, is actually Shock Wave Lithotripsy. Shock Wave has now been available in the US, I believe, close to five years. Initially, it was being used in the SFA and then in the tibials and then eventually the iliacs and now the coronary. Over time, once you start using this technology, you start to figure out places where you think it'll work really well.

We learned over time that it actually can be very beneficial in the common femoral distribution. This is a disease bed that typically is not soft plaque, that typically is dense calcified disease, and doesn't respond to our standard therapies. Doing balloon angioplasty will not work. Doing straight-up drug-coated balloons in this area also will not work due to the dense calcium and the lack of penetration.

[Dr. Sabeen Dhand]
I've done that, where I just do a conventional, like a POBA on a CFA, and I'm like, "I didn't do any--" I tried to convince myself the post-angio is better. I'm like, "Yes, cool," but it's not. It's literally maybe 5% better, when I've used a 7 millimeter balloon, but it doesn't do anything. It's different when you use some other devices, for example, Shock Wave.

[Dr. Mazin Foteh]
Yes, I think Shock Wave has that ability to crack the calcium, change the compliance in the vessel, and ultimately improve luminal gain, which is really what we want. To date, I think I've used it in pretty much all applications of the common femoral. The short eccentric lesions, the long calcified lesions, the occlusions, pretty much every aspect of common femoral disease that you think you can use it in, I've done it. I know where it works well now, and it's a viable technology. It's one that I think in the future may actually be a go-to first for the common femoral. Lots of reasons for that, too.

[Dr. Sabeen Dhand]
Now, are you using-- you mentioned it to soften the plaque. Are you using it as an adjunctive technique as far as to change the compliance and then do something else like DCB or a stent, or are you using it solely by itself and seeing what the post-result is?

[Dr. Mazin Foteh]
Yes. I think there's two avenues for me, one of which is just using Shock Wave alone. Then the other avenue is to use Shock Wave in combination with the DCB. Today, not somebody who's going to stent a common femoral. Not right now. I don't think there's good enough data to support that.

[Dr. Sabeen Dhand]
You're not throwing Superas and all those-- [crosstalk]

[Dr. Mazin Foteh]
Not yet. I know we're going to get into this a little bit, but that's not a part of my practice right now. I tend to treat it basically two ways, as a sole therapy, and if I get a great result from that, then I'm comfortable and I leave it alone. If I get a suboptimal result or if it's a patient who I simply never want to bring back to the operating room or cath lab, then I think it's a good idea to use an adjunctive technology like a DCB to hopefully give you more durable patency over time. That's pretty much how I approach it.

(8) Impact of Endovascular Lithotripsy on Future Surgical Pathways

[Dr. Sabeen Dhand]
Now, in your experience, has this ever burned a bridge as far as going in surgically after you've done a therapy? Say it didn't work that well, are you already prepping the groin for potentially doing an open approach or you plan for that later? Then, does it mess you up at all? Does it make it more inflammatory to-- like when you postplasty a vein and that vein becomes really crappy and you don't want to do surgery on it, is that the same thing that happens on the common femoral?

[Dr. Mazin Foteh]
No, not really. I've been asked two questions. One, "Does it make it worse? Do you somehow compromise what you can do down the road?" Then two, "Does it make what you do down the road any easier?" The answer to both is no. It definitely doesn't burn any bridges. I've never had an embolic event. I've never had an acute occlusion. I've never had anything where I felt like the lithotripsy balloon was the source of that complication.

Then on the flip side, even if I were to cross and I were to treat and I were to open the vessel, when I go back to do an endarterectomy down the road, it didn't make it harder, but it also didn't help it either. I've had I've had device reps ask, "Well, is the calcium softer at that point?" Maybe. Either way-

[Dr. Sabeen Dhand]
It doesn't feel like a rock. Again, when you go in there, you don't feel-- I don't know, at least the ones I've felt, and I've felt way less than you, they don't feel like-- When I first saw this, I expected to feel a rock or something, but calcium is rubbery.

[Dr. Mazin Foteh]
It depends what you encounter. I definitely had scenarios where the artery was so rock hard I couldn't even place clamps because I couldn't occlude the vessel. In fact, there have been scenarios where it was so densely calcified, when I placed the clamp, what happened is the calcium tore the artery through the intima into the adventitia. I've definitely had scenarios like that as well.

[Dr. Sabeen Dhand]
Yikes.

[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. Sabeen Dhand]
That's a good-- because there are people who, [unintelligible 00:37:39] Supera stents, they say, "Okay, you can stent across the CFA." I know there's data out there and whatnot, but it just doesn't sound-

(9) Protecting the Profunda: Managing Risks in Common Femoral Interventions

[Dr. Sabeen Dhand]
One of the things I want to talk about was the profunda. We're talking about CFA, there's no way we can't talk about the profunda. Have you had any plaque shift ever when you postplasty this? Have you compromised the profunda? Obviously, when you stent, you're going to stent across it. That's a big, potential issue. Any issue with your current possible IVL-DCB approach to CFA?

[Dr. Mazin Foteh]
I think one thing you definitely have to be comfortable with if you're going to do common femoral disease interventionally is you have to get comfortable with being able to protect the profunda. Whether that means putting a separate buddy wire in the profunda while you're doing your intervention, whether that means doing a tibial access so you can have one wire across the common femoral retrograde and one wire into the profunda antegrade, you got to protect that artery.

Have I had a plaque shift myself doing lithotripsy alone? No, I haven't. I think that's because we approach the common femoral in a stepwise manner. If the plaque is completely free of the bifurcation, we don't worry, we don't individually wire each vessel. If there was any ever a concern, we take that extra step and we just do it. It's been great for us.

As you know, oftentimes you have to do that anyway because there's spillover disease. The ostium of the profunda, the ostium of the SFA, truthfully, that's the common femoral artery right there. You just have to take care of all the disease. That means doing lithotripsy in the profunda as well as the SFA. No, it's never happened. It is of concern. I do think you need to be careful when you're doing these types of cases because that can happen. Today, I think as long as you're careful, you can do it safely.

[Dr. Sabeen Dhand]
Yes, no, that's great. Yes, and you did mention, too, you haven't had an embolic event, and so you're not typically using filter devices when you're treating the CFA via an endo approach, correct?

[Dr. Mazin Foteh]
That's correct. In the last 10 years, I've never put a filter for common femoral disease, even in scenarios where we were doing atherectomy. We've learned so much in the last decade, where I feel like, although filters are a great safety net, to me, they tend to cause more problems than actually provide any solutions. [crosstalk] Now the atherectomy devices are so advanced. They're doing atherectomy and thrombectomy in combination. These newer devices, I think, are so powerful that if any embolic debris is released, it's immediately suctioned back into the catheter system.

[Dr. Sabeen Dhand]
Yes, and speaking of atherectomy, what's your experience with atherectomy at the common femoral, with devices like Hawk, if you want to go directional, or Rotarex now that's out. They obviously can't go 6 millimeters in, and you can't differentiate going to the media versus-- You're sticking in the intima layer, that's for sure. What's your experience? Do you do it at all, or that's not even on your table?

[Dr. Mazin Foteh]
Yes, so I definitely have done it, and I think I still do it to some degree, but I think it's also important to really choose the proper device if you're going to do a common femoral. The rotational atherectomy devices like Rotarex, which you're mentioning, unless it's an occluded common femoral, that device, quite honestly, is not going to have a major effect because it can't reach the plaque. You're being forced to use directional atherectomy devices like Hawk, potentially Jetstream because it has the cutting blades that can be released, and CSI, a Diamondback. I think those are probably the best options.

I've had some pretty good successes along the way. At the end of the day, it's still the important pieces are choosing the right device, choosing the right size device, and being careful not to create a problem while you're trying to solve this issue.

[Dr. Sabeen Dhand]
Don't embolize.

[Dr. Mazin Foteh]
Yes, don't embolize. Yes, it's easy to say, yes, just don't do it. Of course, it never happens to me. Truth is, just be careful with it. Don't put a [unintelligible 00:42:26] CSI in every single common femoral artery. Small patients use a smaller device.

[Dr. Sabeen Dhand]
No high RPM, all 10 passes.

[Dr. Mazin Foteh]
Yes, don't do 10 passes, and don't do these super long two-minute runs either. Those are going to be issues that get created and probably are self-induced.

(10) Emerging Trials & Multimodality Approaches in Common Femoral Artery Treatment

[Dr. Sabeen Dhand]
Oh, great. Any data or trials that you know right now that will elucidate more what endovascular versus open or help guide us more?

[Dr. Mazin Foteh]
Yes. You had mentioned before Supera, and Supera in the common femoral artery. As you're aware, there's a European trial, Super Surge, which is looking at Supera in the common femoral artery directly against common femoral endarterectomy. I think it's 23 sites across three countries in Europe. They're looking to enroll about 250 or so patients. They're pretty far along the way, and it's going to be a head-to-head analysis of Supera versus endarterectomy. I'm excited to see what the results of that trial are going to be. What I worry, though, is that the results, at least at one year, are very good, and now we get this sudden shift to where everybody starts putting stents in the common femoral artery.

[Dr. Sabeen Dhand]
Yes, you're right on the money. I agree, too, yes.

[Dr. Mazin Foteh]
Yes, and that's probably what's going to happen if the results are really good. Then three years down the road, we're going to be all kicking ourselves.

[Dr. Sabeen Dhand]
Yes, no shit.

[Dr. Mazin Foteh]
Unfortunately, Sabeen, and I think you know this as well, to me, most of the therapies that we do do best when you're doing multimodality therapy.

[Dr. Sabeen Dhand]
Yes, totally.

[Dr. Mazin Foteh]
If it's SFA and you're doing atherectomy with BCB, maybe even a stent in some scenarios, that performs better than just doing POBA, and that performs better than just doing atherectomy and POBA, but no one's ever going to do those trials. No one's going to put up a head-to-head three [unintelligible 00:44:42]

[Dr. Sabeen Dhand]
All those three, that's too much. Yes, there's no way.

[Dr. Mazin Foteh]
It's too much, yes. As an interventionist, I think what works for you. You have your recipe to make the omelet. I think you learn over time what works and what doesn't work and you know how to keep things safe. Everybody goes through that process. The fellows that might be listening to this podcast, I will tell you, not everything you learn in fellowship is what you're going to do when you finally get out and practice. Definitely learn what to do, but also learn what not to do. Learn from the mistakes. You're going to make plenty of them. Even today, I still do. Every day is a school day here in Austin. We're definitely not done with learning at this point.

[Dr. Sabeen Dhand]
Great advice to fellows. That goes to across all specialties and everything. it's true. I do plenty of stuff now that I did not do in fellowship. I learn every single day. It's really nice having mentors. You work with 20-plus surgeons that are great. Then having mentors, it really helps. This was great. I think we definitely covered a lot about CFA disease. Anything else you'd like to mention before we close up?

[Dr. Mazin Foteh]
I just want to give you major props for starting this podcast. I know how busy you are. I've learned so much from a lot of the social media sites, but also from the medical podcasts that have been set up by innovators like yourself. Thank you for taking the time out of your schedule to do this. We're all busy, we all have very busy lives and very busy practices. We don't have the time to sit there and read journal articles all day long. We also don't have the time to reach out to colleagues all day long. I think this has just been a wonderful experience for me and I just want to give you a high five virtually for doing this, man.

[Dr. Sabeen Dhand]
Thanks. Look, the Backtable team, Aaron Fritts, all the hosts, our sound engineers, Karen, Caleb, it's been such an awesome experience for me personally to be a host and just learn from people like you and really just spread the word, because I agree, the last thing I want to do is sit, and sorry, [unintelligible 00:47:04], I don't want to sit and read a journal. I got plenty of things. I'd rather listen to something or [unintelligible 00:47:10] something. I've learned so much from people like you and all these topics. Thanks for the feedback. I appreciate it.

[Dr. Mazin Foteh]
Absolutely, guys. Thank y'all so much for having me.

[Dr. Sabeen Dhand]
Thank you. Thank you so much.

Podcast Contributors

Dr. Mazin Foteh

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

Dr. Sabeen Dhand

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

Cite This Podcast

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

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.