What Classification of the Extent of Atheromatous Lesions on the Femoral Arterial Bifurcation for a Good Endovascular Therapeutic Indication?

The evaluation of the extension of the atheromatous lesion is essential 
for the planning of the endovascular 
technique at the level of the femoral arterial bifurcation. Therefore, we 
changed the classification of Azema and applied it to a series of patients who 
had undergone open surgery of the femoral arterial bifurcation. This evaluation 
made it possible to have an idea of the distribution of atheromatous lesions in 
this region and to compare the efficiency of this modified classification of 
Azema with others used in the literature. This modified 
classification of Azema is relevant and constitutes a decision-making tool for 
the endovascular therapeutic indications of femoral arterial bifurcation.

tween the proponents of open surgery who argue for a better long-term permeability (primary and primary patency assisted at 5 years of age respectively by 91% and 100%) [1]; and the advocates of endovascular treatment who emphasize the reduction of mortality, morbidity and length of stay [2]. Different endovascular approaches (simple angioplasty, cutting balloon, atherectomy, stenting) have been proposed but no consensus exists on the optimal technique. Moreover, while in the field of endovascular therapeutics the anatomy of lesions, especially their extensions, remains the most important decision-making element.
There are several proposals in the literature for classifying atherosclerotic lesions according to their extensions on the femoral tripod [3]. On the other hand, with our experience of endovascular practice, we consider these last insufficient because not taking into account all the possible therapeutic aspects. Therefore, we propose the modification of one of the classifications in order to apply it to a population with atheromatous lesions of the femoral tripod before discussing its efficiency.

Materials and Methods
This is a retrospective study from January 2015 to July 2017 involving 65 pa-

Demographic and Clinical Characteristics
The average age was 69.4 years old. There was a male predominance. The sex ratio was 4:1. The average body mass index was 25.
In terms of antecedents and cardiovascular risk factors, smoking was found in 75.7% of patients, diabetes in 27.1% of patients, hypertension in 61.4% of patients, dyslipidemia in 21.4% of patients; % of patients and cannabis use in 2.9% of patients. In addition, in 8.6% of patients, no cardiovascular risk factors were found.
Two patients (2.9%) were renally impaired at the dialysis stage Clinically, 27% of patients were at stage 3 of the Rutherford classification. The systolic pressure index averaged 0.41 (Table 1).
The arterial lesions were in 57.1% on the right. In four patients the lesions were bilateral. According to the modified classification of Azéma, types I and II were respectively 2.8%, type III was 31.4% (a = 4.2%, b = 20%, c = 7.2% and Type IV was 23% (a = 3%, b = 14.3%, c = 5.7%).

Discussion
The extent of the lesions to be treated is an important morphological criterion to    shown that lesions extended to bifurcations (types III and IV) are associated with a low success rate, a high rate of acute complications and follow-up course [7]. The causes evoked at these high complication rates are directly related to the close relationship between anatomy, flow and distribution of atherosclerotic lesions. Hence the development of stents specifically dedicated to bifurcations.
Some coronary bifurcated stents have recently been used to treat complex lesions of the popliteal trunk [8]. Stenting indications for these type III and IV lesions should take into account the diameters of the target bifurcation. The work of Mishra et al. [9] illustrates the importance of respecting the rule of the three diameters of the main artery and its distal branches. This rule is governed by Murray's law and that of Finet which states that the diameter of the main artery is equal to 2/3 of the sum of the diameters of the distal branches [9]. Indeed, the Type I Type II Type III Type IV use of two stents may compromise this law. Our work provided information on the average measurements of the femoral tripod in terms of length, diameters and angulations that can be used for the design of a bifurcated stent dedicated to the femoral tripod.

Conclusions
The modified Azema classification is an alternative to other means of assessing the extent of atheromatous lesions of the femoral arterial bifurcation. It allows having a global vision and all possible topographical combinations of atheromatous lesions of the femoral arterial bifurcation in order to choose the appropriate endovascular technique.