Duplex-guided Balloon Angioplasty Research Articles

A Case Report of Duplex-Guided Femoral Angioplasty in a Patient with Severe Renal Insufficiency Still an Option to Consider

1.1 Introduction One of the main concern of percutaneous transluminal angioplasty (PTA) is the risk of renal injury in nephropathic patients. A valid alternative is represented by CO2 angiography, which is however contraindicated in patients with chronic obstructive pulmonary disease and is not always available in hospitals. In these cases, the role of duplex guided balloon angioplasty (Du-PTA) should be reassessed. 1.2 Case presentation We describe the case of a 75 years-old nephropathic Caucasian male patient who underwent a duplex-guided percutaneous transluminal angioplasty (Du-PTA) for a 10-cm occlusion of his right femoral superficial artery causing rest pain. A review of the literature about the use of duplex ultrasound for the endovascular treatment of infrainguinal vascular disease in selected high-risk nephropathic patients was also performed. 1.3 Conclusion In well selected patients who present with critical limb ischemia and are at high risk for contrast-induced nephropathy, and when CO2 angiography cannot be performed, Du-PTA of femoral-popliteal district can still be a safe and effective alternative to conventional PTA and should be taken into account.

Comparative study between duplex & angiographic guided angioplasty for failing arterio-venous fistulas

arterio-venous fistulas. Compared with surgery, percutaneous trans-luminal angioplasty (PTA) has several advantages, including simplicity, minimal invasiveness, shorter time and less stress to the patients. It also enables immediate dialysis without the need for central venous catheter, reduces the risk of infection, and saves the patient's veins.6 PTA can be done angiographic or duplex guided. The rationale for duplex guidance is the avoidance of both radiation exposure and contrast reactions. Aim of the study: The aim of this study is to elaborate and evaluate the technique of duplex guided balloon angioplasty for failing AVF in Kasr Elaini Hospitals and to compare it with the angiographic guidance. Patients & methods: This study included 68 patients with failing hemodialysis AVFs (38 males and 30 females). After having informed written consent, every patient was subjected to history taking, physical examination and duplex evaluation. The patients were randomly allocated between two groups of management to have 34 patients in each group. These groups are the duplex guided group (A) and the angiographic guided group (B). The merits and limitations for duplex and angiographic guidance were compared. Results: Duplex guidance obviates the need for contrast injection, radiation exposure and angio-suite. It is a real time and gives an idea about the hemodynamics and is of less cost when compared with angiographic guidance. On the other hand, angiographic guidance is panoramic with better central veins delineation and with significantly shorter duration (ranged from 25 to 50 min with a mean of 36 min± 12). The duplex guided balloon angioplasty duration ranged from 35 to 110 min (mean 45 min ±18) (P value <0.05). Conclusion: Balloon angioplasty for failing AVF is an excellent promising modality for fistula salvage whether done under angiographic or duplex guidance with merits for each.

Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: A new office-based procedure

Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: A new office-based procedure

Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: A new office-based procedure

Unquestionably, the federal government has created financial incentives for vascular interventionists to perform procedures in their offices rather than in a hospital setting. While office venous ablations have been widely embraced by the vascular community, those involving the arterial system have not. One important reason may be related to the cost of the fluoroscopic equipment. Herein, we report on 32 office-based duplex scan-guided balloon angioplasty cases for failing or nonmaturing arteriovenous (AV) access. Twenty-five patients (14 males; 11 females; mean age 65.1 +/- 9.11) with chronic renal insufficiency underwent 32 office-based ultrasound scan-guided balloon angioplasties of their autologous AV fistulas. Twenty-seven procedures were performed in fistulas that did not mature while the remaining five were performed in failing AV accesses. The indications for these procedures were severe stenoses (>70%) as measured by color duplex scan and confirmed by peak systolic velocity (PSV) step-up >3. Preoperative duplex scan-derived mean volume flows (VFs) and highest stenotic PSV were recorded and compared with postoperative findings. Access site puncture and cannulation with short sheath, wire, and balloon advancement and inflation were guided by duplex scan only. A comparison of revenue for hospital-based vs office-based procedures was performed. All procedures were successfully completed without fluoroscopy and contrast material. There were no systemic complications. One patient (3%) developed an arm hematoma due to focal vein rupture which was controlled by a hand compression for 20 minutes. An additional patient (3%) had a focal intraluminal dissection not obstructing the flow. Comparison of preoperative mean VF (350 +/- 180 mL/minute) and postoperative mean VF (933 +/- 332 mL/minute) demonstrated a statistically significant increase with P < .0001. Preoperative mean PSV 582 +/- 923 cm/second decreased to postoperative 1 mean PSV 244 +/- 97 cm/second (P < .0001). After deduction of procedure-related expenses ($730/case) from the global fee, the net income from these 32 cases totaled $51,746, making the return 4.32 times higher than that of the hospital setting (potential professional fee for the same cases - $11,983). This early experience suggests that office-based endovascular repair of AV access under duplex scan-guidance is feasible and safe. The superficial location of AV access facilitates duplex scan visualization. This proposed approach averts contrast material use and radiation exposure. Finally, it appears to be financially more lucrative than the same hospital-based procedures.

Predictive Factors of Femoropopliteal Patency after Suboptimal Duplex–Guided Balloon Angioplasty and Stenting: Is Recoil a Bad Sign?

Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.

Duplex Guided Balloon Angioplasty of Failing Infrainguinal Bypass Grafts

Duplex Guided Balloon Angioplasty of Failing Infrainguinal Bypass Grafts

Commentary on "Duplex-Guided Balloon Angioplasty and Stenting for Occlusive and Stenotic Lesions of the Infrainguinal Arteries"

Commentary on "Duplex-Guided Balloon Angioplasty and Stenting for Occlusive and Stenotic Lesions of the Infrainguinal Arteries"

Duplex-Guided Balloon Angioplasty of Lower Extremity Arteries

The conventional balloon angioplasty of infrainguinal arteries requires the use of fluoroscopy and injection of contrast material. We attempted to perform 360 balloon angioplasties of the superficial femoral (SFA) and/or popliteal arteries under duplex guidance in 274 patients to avoid the nephrotoxic effect of contrast and eliminate or minimize radiation exposure. Critical ischemia was the indication in 35% of cases and severe claudication in 65%. Infrapopliteal angioplasties of 80 arteries were attempted in 54 cases (15% of all cases) in order to improve the run-off after completion of femoral-popliteal angioplasties. For femoral-popliteal segment, overall technical success was 95% (342/360 cases). For infrapopliteal arteries, technical success was achieved in 77 of 80 cases, with an overall success rate of 96%. Twelve-month patency rates for TASC class A, B, C, and D lesions were 90%, 59%, 52%, and 46%, respectively. PAVF <100 mL/min was the most powerful predictor of 30-day and 6-month arterial thrombosis following femoral/popliteal balloon angioplasties.Duplex-guided balloon angioplasty and stent placement appears to be a safe and effective technique for the treatment of femoral-popliteal and infrapopliteal arterial occlusive disease. PAVF <100 mL/min is the most powerful predictor of early (30 days) and midterm (6-month) arterial thrombosis following femoral-popliteal interventions.

Duplex Guided Balloon Angioplasty of Failing Infrainguinal Bypass Grafts

Objective To assess the results of angioplasty and stent placement under duplex guidance for failing grafts. Methods Over 22 months, 25 patients (72% males) with a mean age of 74±10 years presented to our institution with a failing infrainguinal bypass. The site of the most significant stenotic lesion was in the inflow in four cases, conduit in 18 cases and at the outflow in 11 cases. All arterial (20) or graft (13) entry sites cannulations were performed under direct duplex visualization. Duplex scanning was the sole imaging modality used to manipulate the guide wire and directional catheters from the ipsilateral CFA to a site beyond the most distal stenotic lesion. Selection and placement of balloons and stents were also guided by duplex. In 11 cases (33%), the contralateral CFA was used as the entry site and a standard approach (fluoroscopy and contrast material) was employed. Completion duplex exams were obtained in all cases. Results The overall technical success was 97% (32/33 cases). In only one case, the outflow stenotic lesion in the plantar artery could not be traversed with the guidewire due to extreme tortuosity. Overall local complications rate was 6% (two cases). One vein bypass pseudoaneurysm caused by rupture with a cutting balloon was repaired by patch angioplasty and one SFA pseudoaneurysm at the puncture site required open repair. Overall 30-day survival rate was 100%. Overall 6-month limb salvage and primary patency rates were 100 and 69%, respectively. Conclusions Duplex guided endovascular therapy is an effective modality for the treatment of failing infrainguinal arterial bypasses.

Technical Aspects of Infrainguinal Arterial Duplex Guided Balloon Angioplasty

Purpose Duplex-guided balloon angioplasty (DGBA) has been reported in patients with short stenoses. We attempted to perform this procedure in patients with impaired renal function. Methods Over the course of 16 months, 37 lower-extremity DGBAs were performed at our institution in patients with renal insufficiency. Disabling claudication was the indication in 24 cases (65%) and critical ischemia in 13 cases. After duplex-guided common femoral artery (CFA) cannulation, a guide wire was directed into the origin of the superficial femoral artery, across the diseased segment and into the popliteal artery with the help of a guiding catheter under direct ultrasound visualization. The diseased segment was then dilated using a balloon. The balloon diameter and length were chosen according to arterial measurements obtained by duplex. Whenever indicated, stents were placed under duplex guidance. Results Thirty-day survival was 100%. Overall immediate technical success was achieved in all cases. Placement of intraluminal stents were deemed appropriate in 23 of 37 (62%) cases. The 1-month patency and limb salvage rates were 100%. Conclusion DGBA appears to be a feasible, safe, and effective technique for patients with renal insufficiency. Other advantages include guided puncture, accurate balloon and stent selection, and hemodynamic confirmation of the technique adequacy.

Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: An alternative in patients with renal insufficiency

The technique of balloon angioplasty of infrainguinal arteries requires standard arteriography and fluoroscopic guidance. We attempted to perform this procedure under duplex guidance to avoid the use of nephrotoxic contrast material and radiation exposure in patients with renal insufficiency. Over 16 months, 28 patients (17 men) with serum creatinine levels of 1.5 mg/dL or more underwent 37 lower extremity duplex-guided balloon angioplasties at our institution. Ages ranged from 58 to 92 years (mean +/- SD, 74 +/- 9 years). Disabling claudication was the indication in 24 cases (65%), and critical ischemia, in 13 cases. Preoperative duplex arterial mapping showed severe superficial femoral artery and/or popliteal artery stenoses in all cases. No arterial occlusions were treated in this series. Seven procedures (19%) were performed for restenosis. The ipsilateral common femoral artery was cannulated in 32 cases (86%), and the contralateral common femoral artery, in 5 cases (14%), under direct duplex visualization. Contralateral common iliac artery cannulations were performed with the help of fluoroscopy. By using sonographic visualization, a guidewire was directed into the origin of the superficial femoral artery, across the diseased segment, and into the popliteal artery. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Plaque dissections and recoils causing stenosis of 30% or more, a peak systolic velocity ratio of 2 or more, or both were stented under duplex guidance. Arterial duplex examinations and ankle/brachial indexes were obtained before hospital discharge, within 1 month after the procedure, and every 3 months thereafter. Thirty-day survival was 100%. Local complications included one open exploration for expanding hematoma. Technical success was achieved in all cases. Placement of intraluminal stents was deemed appropriate in 23 (62%) of 37 cases. The 1-month patency and limb salvage rates were 100%. Preprocedure and postprocedure ankle/brachial indexes ranged from 0.3 to 0.9 (mean +/- SD, 0.64 +/- 0.16) and 0.64 to 1.2 (mean +/- SD, 0.92 +/- 0.15), respectively (P < .0001). Duplex-guided balloon angioplasty seems to be a safe and effective technique that allows renal patients to experience continued limb salvage and relief from claudication without the risk of developing dye-induced acute renal failure. Other advantages include direct visualization of the puncture site, accurate selection of the proper size of balloon and stent, confirmation of the adequacy of the technique by hemodynamic and imaging parameters, and avoidance of radiation. Although this technique holds considerable potential, longer follow-up will help to fully evaluate its broader applicability.

Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: Early results with a new approach to avoid radiation exposure and contrast material

Balloon angioplasties of stenotic or occluded infrapopliteal arteries may be helpful in selected high-risk patients threatened with limb loss. Thus far, these procedures have demanded fluoroscopy and the injection of potentially nephrotoxic contrast material. Herein, we proposed a new alternative to avoid the harmful effects of radiation exposure and the risk of acute renal failure. Over the last 16 months, 30 patients (57% male) aged 74 +/- 9 years (mean +/- SD) had a total of 52 attempted balloon angioplasties of the infrapopliteal arteries in 32 limbs under duplex guidance. Indications for the procedure were critical ischemia in 20 limbs (63%), including rest pain, ischemic ulcers, and gangrene in 4 (13%), 10 (31%), and 6 (19%) limbs, respectively. Severe disabling claudication was an indication in the remaining 12 limbs (37%). All patients had concomitantly performed balloon angioplasties of the superficial femoral and popliteal arteries (28 cases) or the popliteal artery alone (4 cases). Balloon angioplasty of the infrapopliteal arteries was performed as an adjunct to improve runoff. Hypertension, diabetes, renal insufficiency, smoking, and coronary artery disease were present in 77%, 73%, 50%, 47%, and 37% of cases, respectively. There were 42 cases (81%) with infrapopliteal arterial stenoses (25 tibioperoneal trunks, 9 peroneal arteries, 4 anterior tibial arteries, and 4 posterior tibial arteries) in 26 limbs. The remaining 10 cases (19%) had infrapopliteal arterial occlusions (4 tibioperoneal trunks, 5 peroneal arteries, and 1 anterior tibial artery) in 6 limbs. All these cases were combined with more proximal endovascular procedures (21 femoropopliteal stenoses and 11 femoropopliteal occlusions). All patients had preprocedure duplex arterial mapping and ankle/brachial index (ABI) measurement. Local anesthesia with light sedation was used in all cases. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery and distally, beyond the infrapopliteal diseased segment. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to the arterial measurements obtained by duplex guidance. Completion duplex examinations were performed and postprocedure ABIs were obtained in all cases. Although the overall technical success was 94% (49/52 cases), it was 95% for those with stenoses (40/42 cases) and 90% for those with occlusions (9/10 cases; P < .5). Intraoperative thrombosis occurred in three infrapopliteal cases (two tibioperoneal trunks and one peroneal artery) and in one popliteal artery. All four cases were successfully managed with intra-arterial infusion of thrombolytic agents under duplex guidance. Overall, the preprocedure and postprocedure ABIs ranged from 0.4 to 0.8 (mean +/- SD, 0.58 +/- 0.15) and 0.7 to 1.1 (mean +/- SD, 0.9 +/- 0.16), respectively (P < .0001). Twenty-two (88%) of 25 patients experienced a significant (> 0.15) postoperative ABI increase. Overall 30-day survival and limb salvage rates were 100%. The proposed technique eliminates the need for radiation exposure and the use of contrast material, and it seems to be an effective alternative approach for the treatment of infrapopliteal occlusive disease. Additional advantages include accurate selection of the proper size of balloon and confirmation of the adequacy of the technique by hemodynamic and imaging parameters.