placementhasalsogainedinpopularitywithimprovedoutcomes.15 Unfortunately,stentfractures with diminished patency rates have limited universal adaptation of these practices. Forces on the SFA at the adductor canal, including compression, expansion, torsion, and flexion, adversely impact metallic devices. Mechanical limitations of current stent designs haveledtonew,longerstentdesignswhichmayincreaselongtermpatencyrates.Development of better drug eluting stent and balloon technology may also help to improve outcomes.

Restenosis of stented arterial beds creates a future problem regarding management of in-stent restenosis when it occurs. Plain and cutting balloon angioplasty, cryoplasty, and drug-eluting balloon technology may offer future solutions but currently only anecdotal data exist.16 Research with bioabsorbable stent technology may lead to the elimination of long-term mechanical stent problems and may be a vector for drug delivery directly to diseased segments.17

Other areas of concern for infrainguinal interventions include the common femoral and popliteal arteries which lie at flexion points and the SFA origin where the major branch vessel, the profunda femoris, offers a significant source of collateral flow in cases of limb threatening ischemia. Laser, directional, and rotational atherectomy techniques have been devised as the primary procedure or for debulking diseased segments so that ballooning may be performed with fewer complications. Atherectomy may be a good adjunct in these problem areas and even in highly calcified segments where ballooning and stenting may not be feasible.

Patient treatment and management should not end at the completion of the interventional procedure. Risk factor modification, including diabetic and hypertensive control, statin therapy, smoking cessation, and addition of anti-platelet medication should be individualized for each patient. Personalized health care will continue to become an important aspect of vascular patient care, combining individual genomic information and clinical data with available health information technologies. More aggressive and earlier risk reduction may avert many of the late complications of vascular disease. Health care agencies have clearly begun to recognize the importance of individualized care.18

Optimal wound treatment should be instituted and healing status closely monitored. Patients should be educated about signs of deteriorating vascular status, including recurrent claudication or rest pain and development of new ulcerations. Non-invasive vascular testing may be a helpful addition to physical examination if there is a clinical change. Less circulation is needed to maintain intact skin, so once a wound heals, a decrease in arterial inflow may not necessarily require restoration. This patient is appropriately managed by close follow up, risk factor management, counseling, and protective orthotics. [Q5: D]

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