When Are Stents Necessary for PAD?

Imagine you are trying to drink a thick milkshake through a straw, but someone is pinching the middle of the straw. No matter how hard you suck, the liquid just won’t flow. In your body, your arteries are the straws, and Peripheral Arterial Disease (PAD) is the pinch.

PAD occurs when atherosclerosis—a buildup of cholesterol, calcium, and fibrous plaque—narrows the arteries in your legs. This restricts blood flow, leading to symptoms ranging from leg pain when walking (claudication) to severe foot pain at night and even non-healing wounds.

For many years, the primary solution was simply to inflate a balloon inside the artery to stretch it open (angioplasty). But arteries are elastic living tissues. Sometimes, after the balloon is deflated, the artery snaps back like a rubber band, or the plaque is so heavy that the vessel collapses again.

This is where stents come in.

A stent acts as a permanent internal scaffold, holding the artery open and ensuring blood continues to flow freely. However, stents are not a one-size-fits-all solution. At Fox Vein and Vascular, Manhattan vascular surgeon Dr. David Fox uses a personalized approach to determine exactly when a stent is beneficial and when other options might be better.

In this detailed guide, we will explore the role of stents in PAD treatment, the different types available, and help you understand when this metallic mesh might be the key to saving your limb and restoring your mobility.

What Is a Stent? The Internal Scaffold

A vascular stent is a tiny, expandable tube made of metal mesh. It looks somewhat like the spring inside a ballpoint pen, but much more sophisticated.

How It Works

When an artery is blocked by plaque, the standard first step is often balloon angioplasty. Dr. Fox guides a catheter with a deflated balloon to the blockage site. The balloon is inflated to compress the plaque against the arterial wall, widening the channel.

However, plaque can be stubborn. In some cases, the vessel wall is weak or the plaque is prone to “recoil.” A stent is mounted on a balloon catheter and delivered to the site. When the balloon inflates, the stent expands and locks into place against the artery wall. When the balloon is deflated and removed, the stent remains behind, acting as a structural support to keep the vessel patent (open).

Types of Stents Used in PAD

Not all stents are created equal. Technology has evolved significantly to address the unique challenges of the leg arteries, which must bend and twist as we walk.

1. Bare-Metal Stents (BMS): These are the original stents—simple mesh tubes made of stainless steel or nitinol (a nickel-titanium alloy). They provide excellent structural support but have a higher risk of scar tissue growing through the mesh over time, potentially re-blocking the artery (restenosis).
2. Drug-Eluting Stents (DES): These are a major advancement in Peripheral Artery Disease treatment. The metal mesh is coated with a medication that is slowly released into the artery wall over time. This medication inhibits the growth of scar tissue, significantly reducing the risk of the artery narrowing again.
3. Covered Stents (Stent Grafts): These stents are covered with a fabric-like material (such as PTFE). They create a sealed tube within the artery. These are often used for sealing aneurysms or treating long, complex blockages where there is a risk of the artery rupturing.
4. Bioresorbable Scaffolds: This is the frontier of vascular technology. These stents hold the artery open for a specific period (usually a year or two) and then gradually dissolve into the body. This leaves the artery open but without a permanent metal implant.

When Are Stents Necessary?

Dr. Fox follows a “leave nothing behind” philosophy whenever possible. This means we try to treat the artery without leaving permanent metal implants if we don’t have to. However, there are specific scenarios where stenting for PAD is absolutely necessary and provides the best long-term result.

1. Immediate Recoil (Elastic Arteries)

Sometimes, an artery is very elastic. During an angioplasty, we might inflate the balloon and see excellent flow, but the moment the balloon is deflated, the artery snaps back to its narrowed state. This is called “elastic recoil.” A stent provides the rigid radial force needed to fight this recoil and keep the vessel open.

2. Flow-Limiting Dissection

Occasionally, the pressure from balloon angioplasty can cause a small tear in the inner lining of the artery wall. This flap of tissue (dissection) can hang down into the bloodstream, obstructing flow like a trapdoor. A stent is used to “tack up” this flap, smoothing it against the wall and restoring unrestricted flow.

3. Long or Complex Occlusions

Small, focal blockages often respond well to simple angioplasty or atherectomy. However, if a patient has a long segment of blocked artery (for example, 10 or 20 centimeters long in the thigh), angioplasty alone is rarely durable. The plaque burden is simply too high. Stents are very effective at scaffolding these long segments to ensure blood reaches the lower leg.

4. Calcified Arteries

In patients with diabetes or kidney disease, arteries often become calcified (hardened). This “rock-like” plaque doesn’t compress well. While atherectomy procedure helps remove this calcium, a stent is often needed afterward to ensure a smooth, round channel for blood flow.

5. Iliac Artery Disease

The iliac arteries are the large vessels in the pelvis that supply blood to the legs. Blockages here can cause severe thigh and buttock claudication. Because these arteries are large and don’t bend as much as knee arteries, stents work exceptionally well here and are considered the gold standard treatment.

Learn more about our diagnostic process for determining treatment.

The Benefits of Stenting for PAD

For the right patient, a stent can be a life-changing device.

• Improved Durability: Compared to balloon angioplasty alone, stenting (especially with drug-eluting stents) offers better long-term patency rates. This means the artery stays open longer, reducing the need for repeat procedures.
• Immediate Symptom Relief: By mechanically holding the vessel open, stents instantly restore high-volume blood flow. Patients often report that their leg pain or numbness disappears almost immediately after the procedure.
• Limb Salvage: For patients with Critical Limb Ischemia (CLI)—those suffering from ischemic rest pain, leg ulcers, or gangrene—getting maximum blood flow to the foot is a medical emergency. Stents provide the robust channel needed to heal non-healing wounds and support amputation prevention.
• Minimally Invasive: Like other endovascular procedures, stenting avoids the trauma of open surgery. There are no large incisions, less pain, and a much faster recovery time.

Stents vs. Other PAD Treatments

Stenting is just one tool in Dr. Fox’s toolkit. Understanding how it compares to other options helps clarify why it might be chosen for your specific case.

Stenting vs. Angioplasty

• Angioplasty for PAD: Uses a balloon to stretch the artery.
• Pros: No metal left behind; future options preserved.
• Cons: Higher rate of re-narrowing (restenosis); may not work on recoil.
• Verdict: Angioplasty is often the first step. Stents are used if angioplasty doesn’t yield a perfect result (“bailout stenting”) or for complex lesions where angioplasty is known to fail.

Stenting vs. Atherectomy

• Atherectomy: Physically removes/shaves plaque from the wall.
• Pros: Debulks the vessel; reduces the stretch injury to the wall; leaves no metal.
• Cons: Can create debris (emboli); may still require a balloon or stent afterward.
• Verdict: These are often complementary. Dr. Fox frequently performs an atherectomy to remove the bulk of the plaque (“cleaning the pipe”) and then places a stent to ensure the structure is sound. This combination often yields the best results for calcified arteries.

Stenting vs. Bypass Surgery

• Bypass Surgery: Creates a detour around the blockage using a vein or synthetic tube.
• Pros: Excellent durability for very long blockages; good for active patients.
• Cons: Major surgery; hospital stay; risk of infection; long recovery.
• Verdict: Stenting is much less invasive. Bypass is generally reserved for patients whose anatomy is too complex for stents (e.g., total blockage of all major vessels) or when endovascular attempts have failed.

Explore the full range of minimally invasive treatments we offer.

The Stenting Procedure: What to Expect

If Dr. Fox determines a stent is necessary, here is what you can expect during your visit to our Manhattan vascular surgeon facility.

Preparation

You will undergo a thorough evaluation, including Advanced Arterial Imaging to map the blockage. You will be given instructions on medications (usually starting antiplatelet therapy like aspirin or Plavix) and fasting.

The Procedure

1. Local Anesthesia: You remain awake but sedated. The entry site (usually the groin) is numbed.
2. Access: A small sheath is inserted into the artery.
3. Crossing the Lesion: Dr. Fox navigates a guidewire across the blockage using X-ray guidance.
4. Preparation: Often, the lesion is “pre-dilated” with a balloon or treated with atherectomy to make room for the stent.
5. Deployment: The stent, compressed onto a delivery system, is moved into position. Dr. Fox deploys it, expanding the mesh until it presses firmly against the artery wall.
6. Post-Dilation: A balloon may be inflated inside the stent to ensure it is fully expanded and in contact with the vessel wall.
7. Closure: The catheter is removed, and the puncture site is sealed.

Recovery

Recovery is rapid. You will rest for a few hours to ensure the puncture site is stable. Most patients go home the same day. You may be advised to limit strenuous activity for a few days, but walking is encouraged to keep the blood flowing.

Risks and Limitations: Is a Stent Always the Answer?

While stents are highly effective, they are not without risks or downsides. Dr. Fox weighs these carefully.

1. In-Stent Restenosis

This is the “Achilles’ heel” of stenting. The body perceives the metal stent as a foreign object and may try to cover it with scar tissue. If too much scar tissue grows, it can narrow the artery inside the stent. Drug-eluting stents have significantly reduced this risk, but it still exists.

2. Stent Fracture

The arteries in the leg, particularly behind the knee (popliteal artery), undergo extreme bending and twisting when you walk. Over years, this mechanical stress can cause the metal struts of a stent to fracture. For this reason, Dr. Fox is very cautious about placing stents in “flexion zones” unless absolutely necessary, often preferring drug-coated balloons (DCB) in these areas.

3. Commitment to Blood Thinners

Once you have a stent, you typically must take dual antiplatelet therapy (e.g., Aspirin + Plavix) for a specific period to prevent blood clots from forming on the metal. If you have a bleeding disorder or cannot take these medications, a stent might not be the best choice.

4. Difficulty of Re-Intervention

If a stent becomes blocked, it can be harder to treat than a native artery. You cannot easily bypass a long segment that is full of metal. This is why the decision to stent is never taken lightly.

Treating Associated Conditions

Sometimes, leg pain is multifactorial. While evaluating your blocked leg arteries, Dr. Fox also assesses your musculoskeletal health. Patients with PAD often have co-existing osteoarthritis.

If your vascular condition is treated but you still have recurrent knee pain, you might be a candidate for Genicular Artery Embolization (GAE).

• What is genicular artery embolization? It is a procedure that reduces knee pain by embolizing abnormal capillaries causing inflammation.
• GAE vs knee replacement: It offers a minimally invasive alternative for those who want to avoid major joint surgery.
• GAE recovery time: It is minimal, similar to PAD treatments.

This holistic view ensures that we are treating the patient, not just the X-ray.

Read more about GAE for knee osteoarthritis.

Conclusion: A Scaffold for Better Health

Stents have revolutionized the treatment of Peripheral Arterial Disease. They allow us to take a collapsed, calcified artery and turn it into a wide-open highway for blood flow, all through a pinhole puncture.

Whether you are dealing with early claudication or advanced tissue loss, understanding your options empowers you to make the best decisions for your health. While stents are not always necessary, in the right circumstances, they are the critical link between living with pain and walking with freedom.

If you are experiencing leg circulation problems, cold feet, or slow-healing wounds, do not wait. Early diagnosis gives you more options—including options that might avoid permanent implants.

Take the first step toward better circulation.

Schedule your consultation with Dr. Fox today.

Fox Vein and Vascular – Manhattan, NY
📍 1041 Third Avenue, New York, NY 10065
📞 (212) 362-3470
🌐 foxvein.com

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Note: This content is for informational purposes and does not constitute medical advice. Always consult a healthcare professional for diagnosis and treatment.