Outcomes Of Interventions To Salvage The Jailed Profunda Femoris In Recurrent Limb-threatening Critical Ischemia.

Objective: Crossover stent placement across the profunda femoris artery (PFA) ostium (jailed profunda femoris) during superficial femoral artery (SFA) stenting is increasing, but currently, little is known about the long-term consequences of interventions on jailed PFA when recurrent CLTI occurs. This study aimed to analyze the outcomes of interventions to salvage the jailed profunda femoris in recurrent chronic limb-threatening ischemia (CLTI).

Methods: Between 2010 and 2024, all patients undergoing an intervention for a jailed profunda femoris in the setting of recurrent chronic limb-threatening ischemia (CLTI) secondary to crossover superficial femoral artery (SFA) stent placement were analyzed. Common femoral artery (CFA) stents and PFA ostia with less than 50% stenosis were excluded. Two groups were identified: those presenting with an occluded PFA ostium and those with a stenosed PFA ostium (stenosis>50%). Amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb, endovascular intervention, or major open re-intervention) were evaluated.

Results: One hundred and twelve patients (64% female, 69 ± 6 years, mean ± SD) presented with recurrent Rutherford stage 4 and 5 disease. All had crossover SFA stent placement with currently occluded SFA stents: 67 had a stenosed PFA ostium, and 45 had an occluded PFA ostium with a patent distal PFA. Patients had a median of 4 prior endovascular procedures (range 2-6). Time from initial crossover SFA stent placement was 3.6±0.6 vs. 1.1±0.3 (mean ± SD, yrs; p=0.01) for stenosed and occluded ostia groups, respectively. Sixty-four percent of patients underwent CFA endarterectomy with excision of the stent and patch angioplasty over the PFA ostium, and the remainder received an interposition graft from the proximal CFA to the PFA. 67% required concomitant ipsilateral iliac stenting for significant disease in the common and external iliac arteries, and this was significantly more common in the stenosed group. 26% required an infra-inguinal bypass, with no difference between the two groups. There was no significant difference in 30-day outcomes between patients with stenosed and occluded PFA ostia (MACE: 2% vs. 2%; MALE: 4% vs. 4%; Major Amputation: 2% vs. 2%; stenosed vs occluded PFA ostia, respectively). At 5 years, freedom from MALE (63±4% vs. 51±5%, mean ± SEM; p=0.03) and AFS (69±3% vs. 59±4%; p=0.01; stenosed vs. occluded PFA ostia, respectively) were significantly lower in occluded compared to stenosed PFA ostia groups.

Conclusions: Revascularization of the jailed PFA due to crossover SFA stenting in recurrent CLTI can be achieved with acceptable short-term outcomes and long-term patency. Management of inflow is common, and the need for infra-inguinal bypass is low. There is no difference in outcomes between a stenosed or an occluded ostium in the short term, but they diverge over the long term. In the presence of recurrent CLTI, PFA revascularization is easily achieved and should be considered, regardless of the status of the profunda ostium.