Stenting in other arteries

Dr. TOther 3 Comments

I just learned about a snag. Somebody commented after completion of one of the questionnaires on my website:  “my step sister has multiple stents in the femoral arteries in the legs and is currently experiencing great pain in the leg again. The ultrasound shows the stent is intact and working properly.

This website is of course about coronary artery, not vascular disease, but I can answer this question, as the problem is identical to ones encountered in the heart.

The only way to reply right now is through this blog. I will correct this, but for now, here it goes:

The first question to be answered is whether the leg pain is caused by insufficient blood flow (there are many other reasons for leg pain, such as sciatica, which may be present or co-exist and thus make a diagnosis more difficult).

If the pain is indeed caused by this, there are different options for treatment, all dependent on the nature of the disease. Stents work by stretching and crossing a narrowed area in an artery (the same here as in coronary arteries). To work, a blockage has to be “local”, without up- or downstream obstructions. Particularly in the legs, “atherosclerotic” disease is often extensive and involves many different areas. Fixing one blockage out of many may need not improve the overall blood supply.

Assuming this is indeed a problem of inadequate blood supply, these are the options:

  1. There are obstructions upstream and/or downstream that may or may not be treatable;
  2. There is a better solution for treatment, but it requires an operation by someone else;
  3. An operation is too dangerous because of other illnesses;
  4. This is end stage disease that no longer fixable.

Stents (in coronary arteries or elsewhere) are often placed by physicians not skilled in surgical procedures. As a result, an important part of the evaluation is often not considered, such as whether stenting is indeed the best solution. Too often I have seen patients where this decision was made only because it was so “easy” and because it avoided a “dangerous operation”, not because it was the best solution.

In a recent Cochrane review[i], the authors examined 968 patients with either percutaneous transluminal angioplasty (PTA) alone or PTA with stent placement. At one year, blood flowing through the narrowing in the arteries was no greater in patients with a stent inserted when compared to those without. There was a small improvement in the distance that the patients with a stent could walk up to one year later. However, when asked about their quality of life up to one year later, there was no improvement, whether a stent was placed or not.

If you apply the results of this review to our patient, it is not surprising she is no better off with her stent, even if it works.

The first step then is thus to make sure that stenting was indeed the best solution for her problem, the next whether more can be done, and if so, whether it can be done safely. Last, will any procedure provide our patient with benefits that will help her not just for a few months, but for years to come?

It is this last argument that is so often overlooked in favor of a quick solution, particularly if it provides an economic benefit to the provider!

Dr T

[i] Angioplasty versus stenting for superficial femoral artery lesions , Twine.  Cochrane Database of Systematic Reviews.  v. . no. 1.   2009. p.

Comments 3

  1. Hi Dr. T

    Thanks for the interesting blog.

    I agree with your answer, that the pain may not be related to peripheral artery disease, and, in general, any patient with severe pain should talk about it with her doctor ASAP, in case something serious could be going on.

    The only thing I’d add is that, while stenting is known to have a certain rate of restenosis which we are increasingly realizing happens more often than we’d like, if an ultrasound of the stent shows good flow that problems within the stent are unlikely the source of pain. I’m sure this is what you intended to say.


    Jane Smith

    1. Dear Dr Smith,
      Once again, agreed! This article is about stenting of the Femoral Artery, which often has diffuse disease with multiple areas of obstruction. Stenting of the Iliac Artery (bigger and more upstream), has somewhat better results.
      I am concerned that too often stenting of peripheral arteries such as the FA is performed by doctors who are not vascular specialists and consequently also not trained to consider other causes,
      Dr T

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