Improved Health-Related Quality of Life with Superficial Femoral Artery Stenting in Intermittent Claudication Done Prior to Medical Treatment: A Case Report

In cases involving TASC A lesions of the superficial femoral artery (SFA), the conventional approach typically starts with medical therapy and supervised exercise. When these measures fail to yield the desired results, endovascular procedures may be contemplated. However, in the distinctive case of a 68-year-old male, endovascular therapy was employed to reestablish blood flow through the obstructed SFA segment. This intervention substantially improved the patient’s ability to walk. Subsequently, the patient continued with optimal medical therapy. This integrated approach, beginning with SFA stenting followed by conservative care, promptly alleviated claudication-related symptoms, ultimately resulting in an enhanced quality of life.


INTRODUCTION
Intermittent claudication is a common symptom of lower extremity arterial disease, causing recurrent leg pain during physical activity and impacting daily life.In advanced stages, it may lead to severe symptoms like ulcers and gangrene.Globally, there are around 202 million people with peripheral artery disease (PAD), mainly in low-and middle-income countries.Initial management typically involves medical therapy and lifestyle changes.Surgical revascularization is effective but risky, reserved for non-responsive patients.Endovascular therapy is now challenging conservative measures, with lower risks.This case report discusses a patient with peripheral artery disease who underwent endovascular treatment alongside medical therapy for chronic occlusive disease in the superficial femoral artery, alleviating intermittent claudication. 1,2,3,4

CASE REPORT
The patient is a 68-year-old male residing in the rural aspect of the Lalitpur district with a history of Type 2 diabetes mellitus without diabetic nephropathy.He is an ex-smoker with pack years of 20.The patient had complained of crampy sensations and pain in the right lower leg and foot.These symptoms used to occur consistently after walking for 8-10 minutes (approximately 200 meters) which usually got relieved within 2-5 minutes of rest.However no complains of similar pain were noted at rest or with a simple change in position (standing).He also had experienced dry skin and cold feet.There was a noticeably diminished pulse in the dorsalis pedis artery on the right side, in contrast to normal pulses on the left.Markedly reduced ankle-brachial index (ABI) of 0.42 on the right and a normal ABI of 1.2 on the left.Physical examination of the right lower limb demonstrated signs of poor circulation, including cold, thin, and pale skin with reduced hair, along with a prolonged capillary refill time of 5 seconds.While no evidence of tissue loss like ulcers/gangrenous lesions were present, these findings collectively point to PAD on the right side, necessitating immediate evaluation.The lower limb arterial Doppler findings reveal a complete occlusive thrombus in the distal third of the SFA with a tardus parvus waveform pattern in the popliteal artery, anterior tibial artery and posterior tibial artery suggesting total occlusion of SFA blockage with few collateral formation.CT lower limb angiogram also revealed a similar finding as shown in figure1.

Figure 1: CT Angiogram of bilateral lower limb showing a 5 cm sized filling defect in the course of the distal superficial artery suggesting total occlusion
With the diagnosis of SFA occlusion, the patient was counseled regarding an alternative approach for the treatment of the condition.Since the short segment of the SFA was occluded endovascular revascularisation was put forward as one of the options for treatment.The patient opted for the simultaneous use of endovascular revascularisation and medical treatment for ameliorating his bothering symptoms of intermittent claudication.So the patient was planned procedure of stenting of the occluded superficial femoral artery was done successfully without any immediate complications.(Figure 2)

Figure 2 :
Figure 2: Pre-and post-endovascular treatment angiography.Occluded distal superficial femoral artery (white arrow) with popliteal artery perfused by collateral vessels (angled arrow) in A. Successful revascularization of the superficial femoral artery is shown in B After endovascular therapy, the right ABI showed significant improvement and his intermittent claudication disappeared.He was started on aspirin 100 mg/day and clopidogrel 75 mg/day as dual antiplatelet therapy.He was discharged 5 days later without any complications.After 1 month, the follow-up USG Doppler study revealed a patent stent at the distal superficial femoral artery and any complications at the antegrade puncture site.
In this case, initial revascularisation procedure followed by medical therapy has significantly improved the quality of life.Stenting the superficial femoral artery offers several notable advantages for