Received: 6 July 2021 Revised: 18 October 2021 Accepted: 4 November 2021

DOI: 10.1002/ccd.30020

ORIGINAL STUDIES

Three-year outcome of directional atherectomy and drug

coated balloon for the treatment of common femoral artery
steno-occlusive lesions

Angelo Cioppa MD1 | Michele Franzese MD3 | Donato Gerardi MD2,3 |

Armando Pucciarelli MD1 | Grigore Popusoi MD1 | Eugenio Stabile MD, PhD3 |
1 1 1
Luigi Salemme MD | Lidia Sada MD | Sebastiano Verdoliva MD |
Osvaldo Burattini MD1 | Luigi Fimiani MD1 | Marco Ferrone MD1 |
Giuseppe Di Gioia MD1 | Attilio Leone MD3 | Giovanni Esposito MD, PhD3 |
Tullio Tesorio MD1

1
Interventional Cardiology Service,
“Montevergine” Clinic, Mercogliano, Italy
2
Division of Cardiology, AOR “San Carlo”,
Potenza – “San Giovanni di Dio” Hospital,
Melfi, Italy
3
Division of Cardiology, Department of
Advanced Biomedical Sciences, University of
Naples “Federico II”, Naples, Italy
Correspondence
Angelo Cioppa, Interventional Cardiology
Service, “Montevergine” Clinic, Mercogliano,
Italy.
Email: cioppa68@gmail.com
Abstract
Background: Endarterectomy is considered the gold standard therapy for common
femoral artery (CFA) steno-occlusive lesions, but a significant risk of perioperative
mortality and complications has been reported.
Objective: Aim of this study is to evaluate the efficacy at a long-term follow-up of
patients with CFA steno-occlusive lesions treated with directional atherectomy and
drug coated balloon (DCB).
Material and methods: In this single-center registry, 78 patients (male: 80.7%; age:
71 ± 15 years; occlusions: 25%) with 80 CFA lesions were included, with 39.7% of
them undergoing directional atherectomy and drug coated balloon due to critical limb
ischemia and 60.3% due to lower-limb intermittent claudication. The long-term
follow-up was completed by 75 patients (3 years).
The 31 patients with critical ischemia (39.7%) were further subdivided into
20 (25.6%) patients with pain at rest and 11 (14.1%) with trophic changes, ulcers
and/or tissue loss.
We considered the primary and the secondary outcome, referring, respectively to
peak systolic velocity ratio (PSVR) ≥ 2.4 on duplex or > 50% stenosis on digital sub-
traction angiography at 36 months and to clinically driven target lesion revasculariza-
tion at 36 months.
Results: The primary and secondary outcome was obtained in 84% and 86.7% of
patients, at 36 months of follow up. Bailout stenting was necessary in 6/80 cases
(7.5%) for suboptimal result. Freedom from MALE was obtained in 98.6% of patients.
Conclusions: These results confirm that directional atherectomy and drug coated bal-
loon strategy for the treatment of CFA lesions is effective at a long-term follow-up
and could be considered as a good alternative to surgery.

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2CIOPPA ET AL.
KEYWORDS
common femoral artery, directional atherectomy, peripheral artery disease
1 | I N T RO DU C T I O N
While endovascular intervention is the preferred revascularization
strategy for most peripheral vascular districts, endarterectomy is still
considered the gold standard therapy for common femoral artery
(CFA) atherosclerotic lesions.
Several concerns have been formulated on the percutaneous
treatment of CFA lesions: the high risk of stent fracture in a high
flexion-zone like the hip joint,1 the potential plaque shift or dis-
section into the profunda femoral artery (PFA) or superficial femoral
artery (SFA) in case of distal CFA lesions, the potential post-stenting
side branch jailing, the risk for distal embolization and, finally, the loss
of a femoral access for potential following procedure.
Even if endarterectomy has shown good results at a 7-year follow-
2
up in term of primary patency (PP) and freedom from revascularization,
a significant risk of perioperative mortality and complications (up to 15%
combined mortality and morbidity, with more than 60% of complications
occurring within the first week) has been reported.3 These evidences
highlight the need for a less invasive treatment for CFA lesions.
Several studies explored the outcome of different percutaneous
strategies for the treatment of CFA lesions4–6 providing growing evi-
dences supporting endovascular CFA treatment, therefore the Society
for Cardiovascular Angiography and Interventions (SCAI) Consensus
Guidelines for Device Selection in Femoral-popliteal Arterial Interven-
tions extended stenting to CFA with a IIa recommendation.7
These evidences have led to an increased interest on atherectomy use
in CFA lesions. Atherectomy provides a more advanced plaque modification
technique that removes atherosclerotic/calcified tissue, similar to open sur-
gical technique, resulting in lumen gain without barotrauma. This kind of
lesion preparation is followed by low-pressure balloon angioplasty, decreas-
ing the chance of dissection and avoiding the need for stent placement.
Simultaneously, drug delivery to the vessel wall is increased, low-
ering the chance of restenosis due to neointimal tissue hyperplasia in
the long term.8
This no-stenting approach in the vessel segments may improve
the long-term patency and facilitate future reinterventions, while still
permitting the option of future surgical procedures.
Several prospective multicenter studies have investigated the
safety and efficacy of atherectomy devices in infrainguinal disease,
but few data exist about the CFA district.9
2 | MATERIALS AND METHODS
2.1 | Study design
This single-center registry enrolled 78 patients (male: 80.7%; age: 71
± 15 years) with CFA atherosclerotic disease (number of lesions: 80)
CIOPPA 1311
ET AL3.
undergoing percutaneous revascularization with directional atherectomy
and anti-restenotic therapy (DAART) between January 1, 2012 and
December 31, 2016 due to critical limb ischemia (CLI) or lower-limb
intermittent claudication (IC).
Patients were eligible if they had CFA calcified disease, diameter
of stenosis > 70% and vessel diameter of 5–7 mm.
The anatomic exclusion criteria were: angiographic evidence of
intraluminal thrombosis; spontaneous and/or iatrogenic dissection;
in-stent restenosis; lesion length > 5 cm; calcification grade < 2. The
calcium burden was detected both with duplex scan and with fluoros-
copy and was classified as following: grade 0 = absence of any evi-
dence of calcifications; grade 1 = calcifications at one side of the
lumen with length < 1 cm; grade 2 = calcifications at both sides of the
lumen < 1 cm; grade 3 = calcifications at both sides of the lumen >
1 cm in length.10
The follow-up protocol, which was approved by the institutional
ethics committee specified the patient examinations to be conducted
at hospital discharge, at 30 days, and at 6, 12, 18, 24, 30, and
36 months using duplex ultrasonography. Repeated angiography was
performed when the peak systolic velocity ratio (PSVR) was between
2.4 and 5.0 (intermediate restenosis) in the presence of clinical symp-
toms or > 5.0 (severe restenosis) regardless of symptom status and in
cases of stent occlusion.11
2.2 | Atherectomy technique
All procedures were performed percutaneously, with the patient
under local anesthesia. Vascular access was achieved via the contra-
lateral CFA. A 55 cm 8 Fr long sheath (Cook Medical, Bloomington,
IN, USA) was used in order to achieve adequate support and to allow
continued flushing with saline and/or contrast medium injection while
using the TurboHawk Peripheral Plaque Excision System (Medtronic,
Minneapolis, MN, USA) and HawkOne Directional Atherectomy Sys-
tem (Medtronic, Minneapolis, MN, USA), adopted in 2015 until the
end of enrollment.
Once diagnostic angiography was completed, a wire (0.01400 ),
chosen by the operator according to the stenosis type, was navigated
into the distal superficial femoral artery (SFA). In the case of total
occlusion, a 0.01800 or 0.3500 wire was used to cross the lesion and
was then replaced by a 0.01400 wire.
Balloon for dilation was used only in the case of total occlusion
(n: 20) with an undersized balloon (4 mm diameter), gently dilated at
low-pressure, just to allow the filter and directional atherectomy
(DA) system to get through the lesion. All procedures were performed
using the intraluminal technique.
In order to avoid embolization of atherosclerotic debris, in all
cases, a filter for distal protection (SpiderFX TM; Medtronic,
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CIOPPA ET AL.
Minneapolis, MN, USA), was placed distal to the stenosis prior to the
use of the peripheral directional atherectomy system, adopted a 1:1
filter-to-vessel ratio.
Depending by the lesion anatomy, different strategies were
adopted:
1. in case of 1-0-0 lesion, the filter was positioned in SFA if patent or
alternatively in the PFA in case of SFA occlusion;
2. in case of 1-1-1 bifurcation, the filter was positioned sequentially
in CFA and SFA and the result was optimized with a final kissing-
balloon technique using drug-coated balloons (DCB);
3. in case of 1-1-0 or 1-0-1 bifurcations, the filter was positioned
only in the vessel to treat.12
After filter placement directional atherectomy was performed.
When the DA device nose was filled, it had to be removed and the
atherosclerotic plaque removed from the storage nose cone. The
number of cutting passages was at discretion of the operator. No part
of the atherectomy system was blocked by calcified debris requiring
the use of an additional device.
When the PFA or the SFA was affected, the DA was performed
in each of them.
Summarizing, we have inserted the filter according to the follow-
ing indications:
• for isolated CFA lesions, the filter was placed in the SFA, if patent,
or subordinately, if SFA is occluded, the filter was placed in the
deep femoral artery (PFA).
• in contemporary lesions of SFA and ostial CFA, two filters were
placed alternately according to the cutting directions.
• in CFA and SFA lesions, or CFA and PFA lesions, the filter was
placed in SFA and PFA, respectively.
• When angiograms demonstrated that residual stenosis was lower
than 30%, a post-dilation with IN.PACT Admiral drug-coated balloon
(Medtronic, Minneapolis, MN, USA) was performed (balloon-to-
reference vessel diameter ratio 1:1, 10 mm longer than the stenosis,
lasting at least 180 s).
This is a 0.03500 peripheral balloon catheter coated with a matrix
consisting of a drug (paclitaxel) combined with a hydrophilic spacer
(urea). Provisional stenting was allowed in the case of a suboptimal
result after prolonged balloon dilatations, that is,, flow-limiting dissec-
tion, abrupt vessel occlusion or residual stenosis >50%.
Regard to the periprocedural therapy: all patients received aspirin
(100 mg/day) and should have been on clopidogrel (75 mg/day) for at least
four days. At the time of admission, all patients taking ticlopidine were
switched to clopidogrel. Alternatively, patients received a clopidogrel pre-
load (300 mg) 24 h before the procedure. Post-procedurally, clopidogrel
was continued for 180 days, whereas aspirin was continued for life. 70–
100 IU/kg of heparin was administered before wiring the lesion, with the
intention of achieving an ACT of > 250 s. Additional heparin was adminis-
13
tered at the operator's discretion according to ACT values.
CIOPPA ET AL3.
2.3 | Definition and outcome measures
Technical success was defined as the ability to successfully perform
DA and DCB post-dilation with a residual stenosis <30% or <10% if
bailout stent implantation was necessary.
Procedural success is defined as technical success without the
occurrence of major adverse events during the hospital stay.
Major adverse cardiovascular events (MACEs) included myocar-
dial infarction, stroke, and cardiovascular death.
Major adverse limb events (MALEs) referred to the composite of
acute limb ischemia, major amputation (not including forefoot or toe),
or urgent revascularization (thrombolysis or other intervention for
ischemia).
Arterial inflow revascularization involved any vessel proximal to
the CFA lesion (i.e., aortoiliac segment); arterial outflow revasculariza-
tion involved the SFA, PFA, popliteal artery, or infrapopliteal vessels).
The primary outcome measure was freedom from binary resteno-
sis as determined by a PSVR ≥ 2.4 on duplex or >50% stenosis on digi-
tal subtraction angiography at 36 months.
The secondary outcome was freedom from clinically driven target
lesion revascularization (CD-TLR) at 36 months.
2.4 | Statistical analysis
Continuous data are presented as the means ± SD; categorical data
are given as the number (percentage). Categorical variables were com-
pared using the chi-squared or Fisher exact test as appropriate. The
Student t test for independent samples was used to compare groups
of continuous variables. The threshold of statistical significance was
p < 0.05. Primary and secondary outcomes were represented by the
curves of Kaplan–Meier.
The Kaplan–Meier estimate is one of the best options for calcu-
lating the percentage of subjects who live for a certain period of time
after treatment. In clinical trials, the effect of an intervention is mea-
sured over time by counting the number of subjects who survived or
were saved as a result of that intervention.
All data were analyzed using SPSS software (version 24.0 for
Windows; IBM Corporation, Armonk, NY, USA).
3 | RE SU LT S
From January 1, 2012 to December 31, 2016, 78 patients (male:
80.7%; mean age: 71 ± 15 years; occlusions: 25%) with a total of 80
lesions were enrolled in the registry. All patients were asked written
informed consent for study inclusion. Patients characteristics are sum-
marized in Table 1.
Between the 78 patients, 39.7% of them underwent DAART due
to critical limb ischemia and 60.3% due to lower-limb intermittent
claudication. The long-term follow-up was completed by 75 patients
(3 years).
4CIOPPA ET AL. CIOPPA 1313
ET AL3.

TABLE 1 Baseline characteristics SFA-popliteal occlusion (N = 4) and/or lesion of the BTK ves-

Population characteristic n (%) sels (N = 9).

Angiographic and procedural characteristics are reported in
No. of patients 78
Table 2. All lesions were de novo (100%). Twenty lesions (25%) were
No. of lesions 80
occlusions. Mean lesion length (MLL) was 48.0 ± 17 mm. The majority
Male sex 63 (80.7%)
of lesions (80%) were heavily calcified (calcium score > 3). The bifurca-
Age (years) 71 ± 15
tion lesions were 58 (72.5%).
Hypertension 61 (78.2%)
Technical success was achieved in all treated patients (100%).
Dyslipidemia 50 (64.1%) A simultaneous inflow and/or outflow revascularization procedure
Smoking status Current 6 (7.7%) was necessary in 25/80 cases (31.3%). Chronic total CFA occlusions
Previous 51 (65.3%) (CTO) were recanalized in 20/80 cases (25%).
Diabetes mellitus NID 28 (35.9%) The 25 patients with simultaneous outflow and inflow treatment
ID 13 (16.6%) were divided as follows:
Renal failure eGFR <30 ml/min 10 (12.8%)
Dyalisis 6 (7.7%)
Rutherford class (admission) ≤3 47 (60.3%)
3.1 | In-flow lesions
4 20 (25.6%)
Four patients showed lesions of the common iliac artery and the
5 7 (9%)
external iliac artery proximal to the treatment site. All were preliminar-
6 4 (5.1%)
ily treated with angioplasty and stent implantation (Balloon Expand-
able Stent for ostial and proximal common iliac artery; Self
Expandable Nitinol Stent for distal common iliac artery and external
TABLE 2 Angiographic and procedural characteristics
iliac artery).
Characteristic n (%)
Number of lesions 80
De novo lesions 100% 3.2 | Out-flow lesions
Restenosis 0
In stent restenosis 0 • Twelve patients had critical lesions of the superficial femoral artery

Total occlusion 20 (25%) and the proximal part of the popliteal artery; all lesions were
treated with drug-coated balloon (DCB) angioplasty; bailout ste-
Mean lesion length (mm) 48.0 ± 17
nting was only necessary in two patients.
Minimal luminal diameter (mm) 0.8 ± 0.9
• Nine patients had lesions of the BTK vessels, all treated with angio-
Calcium score > 3 64 (80%)
plasty and DCB. In only two cases, it was also necessary bailout
Bifurcation lesions 58 (72.5%)
stenting, of which in one case Mimic Stent Supera was implanted
Medina classification 1,1,0 34 (55.7%)
in the popliteal artery, while in the other case a coronary cobalt-
of bifurcation lesions 1,0,1 9 (14.7%) chromium stent was implanted in the anterior tibial artery.
1,1,1 15 (18.7%)
DCB diameter, mm 6.3 ± 0.7 Obviously, the outflow lesions were treated after the treatment
DCB length, mm 52.2 ± 14.1 of the common femoral artery.
FKB 21 (26.2%) Bailout stenting was necessary in 6/80 cases (7.5%) for sub-
Post dilatation 28 (35%) optimal result. In these six cases, we used Self Expandable Bare Metal
Bailout stenting 6 (7.5%) Nitinol Stent, because implanted after drug-coated balloon treatment.

Post-procedural dissection 0 (0%)
Associated revascularization 25 (31.3%)
(inflow and/or outflow)
The 31 patients with critical ischaemia (39.7%) were further sub-
divided into 20 (25.6%) patients with pain at rest and 11 (14.1%) with
trophic changes, ulcers and / or tissue loss.
Among 31 patients with critical ischemia, 18 had occlusion or
subocclusion of the common femoral upstream of its bifurcation,
13 had critical common femoral stenosis associated with
No post-procedural dissection was reported. Interestingly, the ste-
nting rate was higher in the early phase of the enrollment, decreasing
as the procedures volume and the operators experience was growing
(Figure 3), reaching a plateau after 30 procedures performed.
No adverse events (MALE or MACE) from intervention to dis-
charge were reported, leading to a 100% procedural success.
There were no complications related to distal embolization, perfo-
ration, or the access site (hematoma needing surgery or bleeding
resulting in a loss of > 3 g of Hb requiring surgery).
There was no acute rupture of the vessel at the treatment site, and no
subsequent pseudoaneurysms formed as a result of the wall collapsing.
1
2 314
CIOPPA ET AL. CIOPPA ET AL5.

F I G U R E 2 Freedom from clinically driven-target lesion

F I G U R E 1 Primary patency after the index procedure [Color
revascularization [Color figure can be viewed at
figure can be viewed at wileyonlinelibrary.com]
wileyonlinelibrary.com]

There was no distal embolization of particles beyond the applied

protective filter in any case.
During the period between treatment and the 36-month follow-
up, 3 patients died: one patient (initially undergoing to bilateral CFA
atherectomy) died due to ischemic stroke, one patient died due to pul-
monary cancer-related complications and one other patient (initially
undergoing to bilateral CFA atherectomy) died due to sudden cardiac
death. This left 75 patients (and 75 lesions) available for the 3-year
follow-up.
At the end of the follow-up period, 12 restenosis > 50% were
observed; consequently, the primary outcome (freedom from resteno-
sis) was obtained in 63/75 patients (84%) (Figure 1).
F I G U R E 3 Bailout stenting rate and procedure volume. The
Of the 12 restenosis, 7/12 (58.3%) occurred in the first 12-month stenting rate was higher in the early phase of the enrollment,
follow-up and 5/12 (41.6%) occurred later. Two cases were in-stent decreasing as the procedures volume and the operators experience
restenosis: one of them occurred at 6 months after the index proce- was growing, reaching a plateau after 30 procedures performed
dure and another one occurred at 23 months after the index [Color figure can be viewed at wileyonlinelibrary.com]

procedure.
Of the 12 restenosis > 50%, 10 patients required a TLR; one
patient reported a major amputation and one other patient was
asymptomatic and did not require TLR.
Among TLR, eight lesions were treated with percutaneous trans-
luminal angioplasty (PTA) and two lesions were treated with surgery.
Only 20% of TLR occurred in stented patients and 80% occurred
in nonstented patients (p = 0.3).
Freedom from CD-TLR was obtained in 65 patients (86.7%)
(Figure 2).
During the entire follow-up, a single case of major amputation
was reported in a patient with restenosis; four other patients reported
a minor amputation (three of them after a TLR). Consequently, free-
dom from MALE was 98.6% (74/75).
The vascular situation at baseline of patients undergoing major
and minor amputations can be summarized as follows: all patients
were diabetic and arrived at treatment in Rutherford class 6; they all
showed trophic lesions: in particular, two patients had foot ulcer (heel
and I toe) and the other two had parcel necrosis of a toe.
Minor amputations are to be referred to surgical therapeutic
completion of revascularization aimed at removing parcel necrosis
of one or two toes in three cases and of a part of the heel in
another case.
The only patient with the major amputation underwent restenosis
in the first 6 months (Figure 3).
4 | DI SCU SSION
This study suggests that the combined use of DA and DCB for the
endovascular treatment of CFA obstructive disease is feasible and
associated with good clinical outcome at a 3-year follow-up.
6CIOPPA ET AL.
At our knowledge, this is the longest follow-up available for a
large population of patients treated with DAART strategy for CFA
lesions.
The need for a less invasive strategy compared to surgery for the
treatment of CFA stenosis has been addressed in several previous studies.
Bonvini et al examined a large series of patients (n = 321) under-
going CFA angioplasty with provisional stenting (37%) and found a
74% PP and 84.1% freedom from TLR4 at a 1-year follow-up.4
The landmark trial that added evidence to the endovascular treat-
ment of CFA was the endovascular versus open repair of the common
femoral artery (TECCO) trial comparing endarterectomy to stenting in
6
117 patients with de novo CFA stenosis. At 24 months, there were no
significant differences in freedom from TLR (HR 0.9; 95% CI 0.3–2.5;
p = 0.83) and primary patency (HR 1.7; 95% CI 0.5–5.6; p = 0.42).
Mehta et al analyzed 167 patients who underwent percutaneous
CFA interventions with PTA only (68.2%), atherectomy ± PTA (22.8%)
and provisional stenting (9%) for failed atherectomy ± PTA. The cumu-
lative patency at 20 months was 85.9% in the atherectomy group and
70.7% in the angioplasty groups.14
Our working-group reported good results at a 1-year follow-up of
a smaller population of patients (n: 30) with severely calcified CFA
obstructions treated with DA and prolonged paclitaxel-coated balloon
angioplasty that showed a 90% primary patency and a 93.3% freedom
15
from TLR.
In a recent experience, Guo et al. performed a 4-year follow-up of
90 patients with CFA lesions (81% IC) treated with PTA (n: 45) or DA
(n: 31) with 87.1% PP in the atherectomy group and 66.7% PP in the
PTA group (p = 0.043). 16
Despite the long-term follow-up, this study included a smaller,
lower-risk population compared to our study, nevertheless the long-
term outcome was similar.
There are numerous treatment options for calcified lesions of the
lower limb arteries in clinical practice. Peripheral intravascular litho-
tripsy (IVL) is a novel calcium modification technique that employs
sonic pressure waves to alter both intimal and medial calcium. The
sonic pressure waves pass harmlessly through the soft tissue and frac-
ture the calcium, minimizing risk to the vessel's noncalcified portions.
Despite a lack of real-world experience, IVL is a safe and effective
treatment option for calcified, stenotic CFAs.17,18
It seems important to remember that this method was not consid-
ered at the time of the procedure because it lacked sufficient evi-
dence and was not available in our catheterization laboratory.
Specialty balloons (e.g., cutting, scoring, ultra-high-pressure) are
being used to treat calcified lesions, although they have limits. Indeed,
balloon dilation might not be strong enough to cause calcium fracture
and arterial expansion. Furthermore, these devices create a significant
amount of barotrauma, increasing the chance of dissection.
The rotational atherectomy (Jetstream) is a rotational cutter that
does not perform directional cutting and will only cut in the center of
the lumen. This, in our opinion, makes it unsuitable for treating large
vessels such as the common femoral artery, despite being the device
of choice for femoropopliteal lesions.19
CIOPPA 1315
ET AL3.
The orbital atherectomy is a novel type of atherectomy that employs
orbital sanding and pulsatile forces to cause cracking in the lesions, all-
owing for easier inflation of a drug-coated balloon. Even this device,
while useful in vessel preparation procedures, appears to be best suited
for small caliber lesions like femoral popliteal and below-knee lesions.20
On the other hand, directional atherectomy and DCB was the
strategy of choice for our study. In a cohort of 78 patients up to
3-year follow-up, the primary patency and freedom from TLR were
84% and 86.7%, respectively. These results confirm that directional
atherectomy and drug coated balloon strategy for the treatment of
CFA lesions is effective at a long-term follow-up and could be consid-
ered as a good alternative to surgery.
5 | LIM ITAT IONS
This is a single center nonrandomized study and the size of the popu-
lation is not really great. The study population is heterogeneous, rang-
ing from patients with claudication to those with CLI. This should
indicate a difference in outcome.
6 | CONCLU SIONS
This study demonstrates good results up to 3-year follow-up of com-
mon femoral artery steno-occlusive lesions treated with DAART strat-
egy. These data are consistent with recent studies and suggest that
directional atherectomy and drug coated balloon could be a safe and
effective alternative to surgery for these patients.
ACKNOWLEDG MENTS
The author Donato Gerardi is currently attending the CardioPaTh
PhD program. The author Attilio Leone is currently attending the
CardioPaTh PhD program.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMEN T
Data available on request due to privacy/ethical restrictions.
OR CID
Angelo Cioppa https://orcid.org/0000-0003-4324-4227
Eugenio Stabile https://orcid.org/0000-0001-9763-6010
Giovanni Esposito https://orcid.org/0000-0003-0565-7127
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How to cite this article: Cioppa A, Franzese M, Gerardi D,
Pucciarelli A, Popusoi G, Stabile E, et al. Three-year outcome
of directional atherectomy and drug coated balloon for the
treatment of common femoral artery steno-occlusive lesions.
Catheter Cardiovasc Interv. 2022;99:1310–1316.
2021;1–7. https://doi.org/10.
https://doi.
1002/ccd.30020
org/10.1002/ccd.30020