Lower Limb Angioplasty Research Articles

Safety of short 3-hour recovery and same-day discharge following lower-limb angioplasty in outpatients with intermittent claudication and critical limb ischaemia

To investigate the safety and efficacy of short recovery day-case pathway following lower-limb angioplasty in both intermittent claudication and critical limb ischaemia patients. A retrospective analysis was undertaken of the medical records of consecutive outpatients treated with lower-limb angioplasty over a 1-year period within an interventional radiology (IR) day-case unit in a high-volume vascular centre. Standard post-angioplasty care at York Teaching Hospital is discharge 3 h after puncture site haemostasis without the routine use of closure devices. The rates of successful same-day discharge, procedure success, complications, and re-admissions were calculated with 30-day follow-up. The cohort included 301 patients (57% intermittent claudication and 43% critical limb ischaemia) undergoing 605 angioplasties using access sheath size ranging from 4 to 7 F. Closure devices were used in only 7% of patients. Successful same-day discharge achieved in 98% of patients (294/301), with seven admitted overnight because of complications. Eleven patients (3.6%) were re-admitted within 30 days. Technical success rates were 92%, and 96% when including partially successful interventions, with 4% technical failure. Twelve patients (4%) developed minor complications and four major complications (1%). There were no significant differences in complication rates between small and larger sheath sizes (p>0.05). No procedure-related death was recorded within 30 days. Lower-limb angioplasty can be performed safely as day-case procedure with a short recovery protocol within IR departments for both patients with intermittent claudication (IC) and critical limb ischaemia (CLI). This may significantly increase patient throughput and alleviate pressure on stretched hospital inpatient resources by safely discharging patients on the day of procedure.

Long-Term Results of the Treatment of Patients With Chronic Ischemia of the Lower Limbs in Combination With Ischemic Heart Disease.

Aim To compare long-term outcomes of x-ray endovascular (percutaneous coronary intervention, PCI, and lower limb angioplasty with stent placement, LLA; group 1) and combination treatments (PCI and open LLA surgery; group 2) in patients with chronic lower limb ischemia (CLLI) associated with ischemic heart disease (IHD).Material and methods This retrospective study has been conducted in the Vishnevsky National Medical Research Center of Surgery since 2019. The study includes 92 patients with stage 2B CLLI associated with IHD who were managed from January 1, 2017 through December 31, 2020. Long-term outcomes were evaluated in 76 (82.6 %) patients. The endpoint was severe cardiovascular complications (CVC), including death, myocardial infarction, and acute cerebrovascular disease (ACVD).Results In group 1 during the long-term period, 1 (2.7%) fatal outcome due to pneumonia was observed. In group 2, 4 (10 %) patients died: 1 (2.5 %) patient due to ACVD, 1 (2.5 %) patient due to progression of oncological process, and 2 2 (5 %) patients due to COVID-19. Also, 2 (5.5 %) and 1 (2.5 %) cases of acute coronary syndrome (ACS) were observed in groups 1 and 2, respectively (p=0.61).Conclusion In the x-ray endovascular (group1) and the combination (group 2) intervention groups, lethal outcomes due to myocardial infarction were absent. This fact confirms the importance of PCI in patients with CLLI for prevention of possible ACS in the long-term. Both therapeutic tactics in managing CLLI patients with IHD demonstrated high safety and clinical efficacy during the hospital and long-term periods and can be extensively used in routine clinical practice.

Impact of COVID-19 on angioplasty service and outcome of patients treated for critical limb ischaemia

Abstract Background Peripheral artery disease (PAD) is a major challenge worldwide and endovascular revascularization is an important component of treatment that is affected by COVID-19 restrictions. Purpose Here, we evaluated the impact of COVID-19 restriction on angioplasty service and outcome of patients undergoing lower limb angioplasty. Methods Consecutive patients undergoing endovascular revascularisation between August 2018-March 2021 in a UK district general hospital were analysed retrospectively. Indications for angioplasty of all patients were discussed and agreed upon in multi-disciplinary teams. We compared time from referral to angioplasty, patient and procedural characteristics, technical success, peri-procedural complications, and outcome (wound healing, major amputation, target lesion revascularization, death) in patients treated 'before' and after February 2020 (“during COVID-19”). Results One hundred nineteen patients were treated 'before' (92% critical limb ischaemia [CLI]; 60% diabetes mellitus) and 72 were treated 'during COVID-19' (96% CLI; 61% diabetes mellitus). While the total monthly number of patients treated did not change, the number of outpatients treated as day cases increased (40% to 72%) and overnight stays for social reasons decreased (16% to 10%). Treatment of hospitalized patients decreased from 44% to 18%. The percentage of outpatients treated at <14 days after referral increased from 39% to 63% and hospitalized patients treated <5 days from 47% to 54%. Neither COVID-19 nor time to procedure affected wound healing (p(log Rank) = 0.451; median time to healing 168±25 days) and amputation free survival (p(log Rank) = 0.924; median survival 368±30 days) in all CLI patients significantly. However, amputation-free survival was significantly worse in hospitalized as compared to outpatients (p(log Rank) <0.001; median survival 155±20 vs 368±30 days) with similar wound healing in those that survived (p(log Rank) = 0.340; median time to wound healing 168±25 days). Of note, the known causes of death were sepsis (32%), pneumonia (18%), COVID pneumonia (18%), cardiac (16%) and stroke (8%). Conclusions Adapting to COVID-19 restriction we maintained a safe and effective angioplasty service while shortening waiting times. Very high mortality rates in patients after hospitalization indicated that CLI need to be treated much earlier and more aggressively to avoid disease progression requiring hospitalization. Funding Acknowledgement Type of funding sources: None.

Interventional Radiology Awareness among the Final‑Year Medical Students in Riyadh

Objective: Interventional radiology (IR) is experiencing massive growth in the medical scene as new interventions are being introduced continuously to contribute to patient care. However, IR does not go without its fair share of challenges. Personnel shortages, turf wars, and a vague understanding of the role of IR in the hospital setting by medical students are a few. The latter could negatively impact the recruitment of young prospects and contribute to further personnel shortage. To combat this, we aimed to assess the final-year medical students' awareness of IR. Methods: This was a cross-sectional, self-administered questionnaire study. Our target population was all final-year medical students at university-based medical schools. Surveys were sent to 822 students, and a total of 719 final-year medical students responded (87.5%). The survey was distributed anonymously during November and December 2018. The survey consists of 21-closed and open-ended questions. Results: The vast majority of the respondents felt that their knowledge of IR was poor (83%), while a few reported that they had a good grasp of IR (16%). Half of the respondents believe that an Interventional Radiologist (IRs) must complete training in radiology. However, 42% thought that radiology and surgery was the correct route of training for IRs. Seventy-one percent and 73% of the final-year medical students correctly identified that IRs perform uterine artery embolization and lower limb angioplasty, respectively. A majority (68%) of the respondents believe that IRs perform cardiac angioplasty and stenting, whereas 57% believe that they perform femoral-popliteal bypass. Conclusion: Our data suggest that knowledge, awareness, and exposure of the final-year medical students to IR are overwhelmingly poor in the region. This can be ameliorated through a number of means, such as directly involving IRs in the medical student curriculum, IR awareness campaigns, and IR symposiums.

Cultural and psychological determinants of pain assessment during lower limb angioplasty

Introduction. It is a common unofficial perception of surgeons performing endovascular operations that patients living in the different social and economic environment assess pain differently during peripheral angioplasty procedures. The objective was to examine the differences in assessing pain experienced during endovascular arterial interventions on lower limbs, by Polish and German patients, and to analyse the psychological determinants of the assumed differences, by referring to mental dispositions such as optimism and satisfaction with own life quality. Material and methods. 101 patients were qualified for endovascular intervention on lower limbs arteries — 51 Germans (M = 67.31; SD = 9.82) and 50 Poles (age M = 67.88; SD = 8.4). 37 women and 64 men were classified as Rutherford category 2–3. Three scales were applied: 1. Life Orientation Test-Revised 2. Satisfaction With Life Scale 3. Pain Appraisal Scale which comprises emoticons showing subsequent degrees of sustained pain and the corresponding Visual Analogue Scale. Results. The patients from Poland graded their life quality lower than the German patients (M = 23.44; SD = 5.977 and M = 25.94; SD = 5.584). The Poles presented a lower level of optimism (M = 15.04; SD = 3.703 vs M = 15.8; SD = 3.516). The Polish patients classified the level of pain during lower limb angioplasty as higher than in German patients (M = 4.22; SD = 2.999 and M = 2.88; SD = 2.215) (p < 0.012). Conclusions. Resistance to pain experienced during endovascular procedures probably depends on the assessment of the patient’s current life situation, determined by satisfaction with own life quality and related optimism. With great caution, it might also be supposed that resistance to pain depends on the life standard typical of a given population

Forced-Air Warming in Patients Undergoing Endovascular Procedures: Comparison between 2 Thermal Blanket Models

The purpose of this study was to compare the efficiency between 2 thermal blanket models: the upper blanket and the underbody blanket in patient heating and hypothermia prevention during endovascular surgery. Fifty patients, American Society of Anesthesiologists physical status 2-4, receiving endovascular surgery repair of infrarenal abdominal aortic aneurysm or lower limb angioplasty by endovascular technique were studied. Primary outcome was to determine which forced-air blanket is more warming effective during the surgeries. Age, type of surgery, gender, body mass index, surgery duration, and initial patient temperature were analyzed to determine possible hypothermia association as secondary outcomes. Patients were randomized and split into 2 groups based on blanket model. All patients received general anesthesia, and temperature was obtained by an esophageal thermometer inserted after tracheal intubation and registered at intervals of 15 min until extubation. Groups significantly differed in body temperature (P = 0.006) and hypothermia occurrence (P = 0.020). The underbody blanket group hada higher ratio of hypothermic patients and a lower average temperature at the end of surgery. The average temperature after 60 min in the underbody blanket group was lower than the upper blanket group,although this difference was only significant after 150 min (P = 0.020). We conclude that upper thermal blanket is more effective thanunderbody thermal blanket in patient warming and hypothermia prevention during endovascular abdominal aortic aneurysm repair and lower limb angioplasty after 150 min of anesthetic-surgical time duration.

A Case of Proximal Deep Vein Thrombosis Following Lower Limb Angioplasty

Peripheral arterial disease can be treated with angioplasty. Complications of percutaneous angioplasty include arterial occlusion, thromboembolism and arterial rupture. I report a case of lower limb proximal deep vein thrombosis (DVT) that developed 1 day after a peripheral arterial angioplasty via common femoral artery approach. My literature search failed to identify any previously reported cases. The incidence of DVT following coronary intervention via femoral artery catheterization was reported to be 0.05% but the incidence of DVT following peripheral angioplasty remains unknown. This case showed that DVT can happen after peripheral angioplasty and further studies should be conducted to document its incidence. This also raised the point if routine short course of anticoagulation is required after angioplasty of lower limb to prevent DVT.

Clinical Utility of a New Predicting Score for Radiocephalic Arteriovenous Fistula Survival

Radiocephalic arteriovenous fistula (RC-AVF) is the recommended first choice for vascular access (VA). The CAVeA2T2 scoring system was recently published (ipsilateral central venous catheter access, age >73years, vein <2.2mm, lower limb angioplasty, and absent intraoperative thrill). The aim of the present study was to assess the clinical utility of the CAVeA2T2 scoring system for predicting RC-AVFs survival in our center and its subsequent application in VA management. In this single-center retrospective study, all RC-AVFs performed from January 2010 to July 2014 were included. The CAVeA2T2 was applied. Primary, assisted primary, and secondary patency rates were measured. Sixty RC-AVFs were analyzed. Mean age was 64.3±14.7years. Mean CAVeA2T2 score was 1.23±1.2. The median fistula secondary patency was 13.7±1.6months. Secondary patency was at 6weeks and at 6, 12, and 24months: 88.3%, 66.7%, 55%, and 31.7%, respectively. Increasing score (≥2) was associated with a decrease in primary (log-rank, χ2 = 16.7, dif= 1, P=0.0001) and secondary patency rate survival (log-rank, χ2 = 5.4, dif = 1, P=0.0001). In addition, stratification of the CAVeA2T2 score into 3 groups (scores 0-1, 2, and 3+) retained its significance for primary (log-rank, χ2 = 19.4, dif = 2, P=0.0001) and secondary patency rate survival (log-rank, χ2 = 5.5, dif = 2, P=0.046) at the end of the study. In the present study, the CAVeA2T2 scoring system has proved to be a useful, easy to apply tool that is highly predictive of RC-AVF survival. Based on our results, we should avoid perform RC-AVFs, in those patients with CAVeA2T2 score ≥2 and late nephrology referral. Prospective studies should be designed to establish the management of patients with a higher CAVeA2T2 score.

Predicting outcomes in native AV forearm radio-cephalic fistulae; the CAVeA2T2 scoring system.

The aim of this study was to identify significant factors relating to fistula survival and create an easy-to-use scoring system for predicting fistula patency rates. A total of 276 consecutive radio-cephalic forearm fistulae created in a single tertiary vascular unit were identified retrospectively. Numerous patient- and fistula-related demographics were noted. Cox regression analysis was used to identify significant factors predictive of reduced fistula patency rates, and significant variables weighted according to their hazard ratio. Five significant factors were identified: ipsilateral Central venous access, Age >73 years, anastomosed Vein <2.2 mm, previous lower limb Angioplasty and absent intra-operative Thrill (1 point for first three variables, 2 points for the latter two). The CAVeA2T2 score (maximum 7 points) significantly predicted for reduced fistula patency (p = 0.001) and a reduced rate of successful dialysis (p = 0.001). Fistulae with CAVeA2T2 scores ≥2 had 6 week and 1 year patency rates significantly below pooled published rates. Without scoring for thrill, that is in the pre-operative setting, the scoring system remained significant at all stages. The CAVeA2T2 scoring system is a potential scoring system for predicting fistula patency rates and the likelihood of dialysing through a fistula. Further studies and/or external validation is required in the context of methodological limitations. How to manage patients with a high CAVeA2T2 score is unknown.

Pseudoaneurysm of the sural artery: a rare complication of lower limb angioplasty

Percutaneous transluminal angioplasty (PTA) is a common therapeutic option for the treatment of peripheral vascular disease. Pseudoaneurysm at the puncture site is a well-documented complication in patients. This case report describes a patient who presented to hospital several days following a left superficial femoral and popliteal artery PTA with lower limb pain and swelling. The working diagnosis included a deep vein thrombosis based on the Wells criteria. However, a combination of a duplex scan and computed tomography angiography confirmed a clinically rare occurrence of pseudoaneurysm of the sural artery, a branch of the popliteal artery. This was managed successfully with a thrombin injection, leading to complete resolution of the patient's symptoms. This case highlights the importance of the technical aspects of performing a PTA. We believe that the guide-wire position was not confirmed to be completely in the popliteal artery upon inflation of the balloon.

Functional lengths of the lower limb arterial tree measured by CT angiography centreline analysis: implications for catheter lengths in peripheral angioplasty

Lower limb angioplasty is a common procedure. However, arterial lengths have not been well studied and there is no evidence base for the optimum catheter lengths required for the various applications of femoral or distal below-the-knee angioplasty. The industry standard catheter measures 80 cm. Fifty CT angiograms were post-processed using vessel tracking and centreline analysis tools and lengths were measured from the ipsilateral first segment of the femoral artery (FSFA) (common femoral artery) to the contralateral FSFA and on to the second segment of the femoral artery (superficial femoral artery) and popliteal arteries down to the posterior tibial (PT) artery at the ankle. This allowed clinically meaningful lengths for 'cross-over' and 'antegrade' angioplasty to be calculated. Mean cross-over length to the second segment of the femoral artery as it crossed the femoral cortex was 72.3 cm, and the mean cross-over length to the popliteal artery at the knee joint was 83.8 cm, and the length from the FSFA to the PT was 85.1 cm. Selection of a standard length catheter can result in a situation where the catheter is too short. Optimum catheter length for a particular task will reduce the need for catheter exchanges and use of multiple balloons and therefore reduce complications, procedure time, radiation dose and cost.

Treatment of infrainguinal thromboembolic complications during peripheral endovascular procedures with AngioJet rheolytic thrombectomy, intraoperative thrombolysis, and selective stenting

This study investigated the safety and effectiveness of the infrainguinal use of the AngioJet rheolytic mechanical thrombectomy system (Possis Medical, Minneapolis, Minn) for the treatment of acute infrainguinal thromboembolism occurring during lower limb revascularization procedures. For the interval between January 2000 and January 2011, our hospital's database was meticulously searched for all patients with acute thromboembolism that occurred during lower limb angioplasty, with or without stenting procedures, who were treated with infrainguinal AngioJet thrombectomy. Baseline patient demographics and procedural details were analyzed. Primary end points included technical success, defined as the complete revascularization of the acutely occluded vessel; clinical success, defined as the absence of death or amputation ≤ 60 days; and procedure-related complication. Secondary end points included embolized vessel primary patency and overall patient survival. During this 12-year period, 3147 peripheral percutaneous procedures of angioplasty, with or without stenting, were performed in our department. Intraoperative, clinically, and angiographically evident thromboembolism occurred in 18 of 3147 procedures (0.57%), and 14 (77.7%) were managed using the AngioJet thrombectomy system. In total, 22 arteries were treated (13 infrapopliteal, 3 femoropopliteal, and 6 popliteal arteries). All patients had a completion angiogram for the assessment of the runoff vessels' status. Technical and clinical success occurred in 13 of 14 (92.8%). Adjunctive local thrombolysis or clot trapping, or both, with stenting was used in 64.3% and 42.8% of the procedures, respectively. Mean time follow-up was 38.1 ± 49.0 months. The 1-year embolized vessel primary patency rate was 50.9%, and the survival rate was 53.5% up to 11.5 years of follow-up, as estimated by Kaplan-Meier analysis. The 1-year limb salvage rate was 92.3%. There were no procedure-related minor amputations and one (7.1%) procedure-related major above-knee amputation. The use of AngioJet rheolytic thrombectomy and adjunctive local thrombolysis or stenting, or both, under filter protection, is safe and effective for the management of severe thromboembolic complications occurring in the femoropopliteal and infrapopliteal arteries during peripheral endovascular procedures.

Radial artery access for above the knee angioplasty: a feasibility study

Lower limb angioplasty is usually performed by transfemoral access despite the risk of local complications. Transradial access (TRA) has gained acceptance for coronary interventions. The aim of this study was to evaluate the feasibility and safety of TRA for above the knee (ATK) angioplasty. Twenty-five consecutive patients (eight females; mean age 72, range 55-85 years; seven symptomatic for critical limb ischaemia, 18 for claudication) underwent ATK angioplasty by left (19) or right (6) TRA. A total of 32 lesions were addressed; 16 stents were positioned in 12 patients with an overall success rate of 81%, and a success rate of 38% on occlusions and of 96% on stenoses. The overall success rate on the 16 supra-inguinal lesions was 81%, (success rate 60% on occlusions and 91% on stenoses). The overall success rate on the 16 infra-inguinal lesions was 81%, (success rate 0% on occlusions and 100% on stenoses). Any haemorrhagic complications or local complications needing surgery were observed in the cohort of patients. TRA can represent a feasible and safe alternative for ATK angioplasty in case of difficult femoral access.

An analysis of vascular surgery in elderly patients to determine whether age affects treatment strategy

The incidence of arterial disease increases with age. Increasing life expectancy in the western world will intensify demands on vascular surgeons with regard to increasing caseload, expanding patient selection criteria, and more complex and minimally-invasive treatment options. We analysed our arterial cases over the past 31 years (n = 6,144) and compared our methods of intervention and complication rates in the elderly population (>75) with the younger cohort, in order to determine whether age should influence our management strategies. Data were collected prospectively on all arterial cases from 1978 to 2009. Methods of intervention and corresponding complication rates in the over and under 75-year-old cohorts were analyzed utilizing Fisher's exact test to calculate two-sided p values, relative risks and 95% confidence intervals. Endovascular management has evolved to become the first line approach for all arterial cases (except carotid disease). Age was a significant risk factor for death and MI for the open procedures of AAA repair (p = 0.049 and p = 0.007, respectively), aorto-bifemoral reconstruction (p < 0.0001 and p = 0.006) and lower limb bypass (p = 0.01 and p < 0.001). For endovascular procedures, age did not impact on MI rate for EVAR (p = 0.78) or death rates for EVAR (p = 0.46), iliac angioplasty (p = 0.62) or lower limb angioplasty (p = 0.29). A paradigm shift has occurred towards endovascular management of aortic, iliac and femoral arterial disease. Whilst patient age >75 significantly impacts on complication rates from index open vascular procedures, age does not impact upon complication rates of corresponding endovascular procedures. We, therefore, recommend an endovascular approach be adopted as first line for all patients, regardless of patient age.

Patient Experience, Pain, and Quality of Life after Lower Limb Angioplasty: A Multisite Prospective Cohort Study

To explore the experience of patients undergoing endovascular lower limb angioplasty and evaluate the improvements in quality of life and disease-related symptoms after the procedure. Patients completed a questionnaire before treatment and three questionnaires after the procedure (immediately after the procedure, and again 4 weeks and 3 months later). Anxiety, patient understanding, procedure-related pain, and disease-related pain were assessed by a visual analog score (VAS). Complications, analgesic requirements, and satisfaction were recorded. Changes to quality of life were assessed by the validated SF36 questionnaire. A total of 88 patients (41%) responded. Overall, disease-related pain decreased over 3 months after the procedure. Smokers had more pain both before and after the procedure (P < 0.05). Explanation was considered better if provided by radiologist (P < 0.05). Sixty-nine percent of patients found the procedures less painful (mean VAS 2.5) than they had anticipated (VAS 5.5). Fifty percent of patients experienced adverse effects related to their puncture site, but this was highest among patients who had undergone the procedure before and smokers. The greatest quality-of-life improvements were in emotional and general health. Higher levels of disease-related pain were associated with worse general, emotional, and physical health (P < 0.05). Lower limb angioplasty provides symptomatic and quality-of-life improvements. Implementation of simple measures could improve patient satisfaction-for example, treatment should be explained by the radiologist in advance. Routine prescription of analgesics with particular attention to smokers and those undergoing repeat interventions is suggested.

Access to the Superficial Femoral Artery in the Presence of a “Hostile Groin”: A Prospective Study

Lower limb angioplasty is commonly performed via antegrade common femoral artery (CFA) puncture, followed by selective superficial femoral artery (SFA) catheterization. Arterial access can be complicated by a "hostile groin" (scarring, obesity, or previous failed CFA puncture). We prospectively investigated color duplex ultrasound (CDU)-guided SFA access for radiological interventions. Antegrade CDU-guided CFA and SFA puncture were compared in 30 patients requiring intervention for severe leg ischemia who had hostile groins. Demographics, screen time, radiation dose, intervention, and complications were prospectively recorded. Treatment in 30 patients involved 44 angioplasties (40 transluminal, 4 subintimal) and 2 diagnostic angiograms. Fifteen of these patients had CDU-guided CFA punctures; in 8 of these patients CDU-guided CFA puncture "failed" (i.e., there was failure to pass a guidewire or catheter into the CFA or SFA), necessitating immediate direct CDU-guided SFA puncture. Overall, the mean screen time and radiation dosage, via direct CDU-guided SFA puncture in 30 patients, was 4.8 min and 464 Gy cm(2) respectively. With CDU-guided CFA puncture, mean screen time (10 min), radiation dose (2023 Gy cm(2)), and complications (13%) were greater when compared with the SFA puncture results overall and in the same patients at subsequent similar procedures (2.7 min, 379 Gy cm(2) (p < 0.05), no complications in this subgroup). Five complications occurred: 2 each at CFA and SFA entry sites, and 1 angioplasty embolus. The CDU-guided SFA puncture technique was both more effective than CDU-guided CFA access in patients with scarred groins, obesity, or failed CFA punctures and safer, with reduced screen times, radiation doses, and complications.

Second Best Medical Therapy

Background : best medical therapy (BMT) provides patients with peripheral arterial disease (PAD) substantial protection against future vascular events. Objective : to determine the quality of BMT received by PAD patients in this vascular surgery unit. Methods : retrospective case-note review of 50 consecutive patients in each of the following groups: intermittent claudication (out-patients), symptomatic carotid artery disease (out-patients), lower limb angioplasty, lower limb bypass surgery, carotid endarterectomy. Results : overall BMT use was poor. Fifteen percent of smokers had assistance with smoking cessation noted. Seventy-eight percent of patients were taking an antiplatelet agent, 38% cholesterol-lowering medication and 51% antihypertensive medication. Fifty-three percent of patients had a cholesterol measurement, 50% of out-patients had a blood pressure measurement and 53% of non-diabetics had a random blood glucose performed. Sixteen of the patients with lower limb disease were given advice about exercise. Patients with a history of coronary artery disease were more likely to be taking cholesterol lowering, or antihypertensive medication. Conclusions : BMT is poorly used in patients with PAD, which will result in an excess of cardiovascular morbidity and mortality. Strategies need to be developed to increase the use of BMT in our patients.

Angioplasty of Lower Limb Arterial Stenoses under Ultrasound Guidance: Single-Center Experience

Purpose: To examine the feasibility and utility of ultrasound-guided angioplasty for treating lower limb stenoses. Methods: Duplex ultrasonography was employed to guide 55 balloon dilation procedures (27 iliac, 26 superficial femoral, 1 profunda, and 1 vein graft) with the help of a special ultrasound catheter (EchoMark). Ultrasound was used to determine balloon size, monitor guidewire passage, direct the dilation, and judge procedural success. Angiography was performed prior to the procedure to confirm preprocedural ultrasound findings and afterward to compare with duplex visual and hemodynamic parameters of success (peak systolic velocity ratio &lt; 2.0). Results: The balloon size determined from duplex measurements correlated in all cases with sizes selected based on the angiographic image. Guidewire visualization was possible in 95% of the cases. Angioplasty using ultrasound alone was feasible in 84%; inability to obtain a satisfactory image owing to vessel tortuosity, calcification, and bowel gas accounted for the failures. Against the duplex success criterion, initial completion angiograms had an accuracy of 76%, sensitivity of 76%, and specificity of 100%. The additional time for ultrasound guidance averaged 42 ± 12 minutes for all cases. Conclusions: Our results show that ultrasound guidance is feasible in routine clinical practice. In this series of well-selected cases of arterial stenoses, angioplasty was performed safely using ultrasound guidance alone in over 80% of the cases. Fluoroscopic monitoring is needed when ultrasound visualization is suboptimal.

Ultrasonic plaque character and outcome after lower limb angioplasty

Purpose: The value of ultrasonic plaque characteristics in identifying patients at “high-risk” of restenosis after percutaneous transluminal angioplasty (PTA) was studied. Methods: Thirty-one arterial stenoses (6 common iliac, 2 external iliac, 1 profunda femoris, 21 superficial femoral, and 1 popliteal) in 17 patients who underwent angioplasty were studied by means of duplex scanning. With a computer-based program, B-mode images were digitized and normalized using 2 reference points, blood and adventitia. A grey level of 0 to 5 was allocated for the lumen (blood) and 180 to 190 for the adventitia on a linear gray scale of 0 to 255 (0 = absolutely black; 255 = absolutely white), and the overall plaque gray-scale median (GSM) of the pixels of the plaque was used as a measure of plaque echodensity. After PTA, follow-up of stenoses was done on day 1, weekly for 8 weeks, at 3 months, 6 months, and 1 year. The total plaque thickness (sum of anterior and posterior components), minimal luminal diameter (MLD), and peak systolic velocity ratio (PSVR) were measured for all stenoses. An increase of more than 2 in the PSVR was the duplex criterion used to signify restenosis. Results: The GSM of the stenoses before angioplasty ranged from 6 to 71 (mean, 31.3 ± 17.9); 17 stenoses had a GSM less than 25 (mean, 18.7 ± 5.3), and 14 had a GSM more than 25 (mean, 46.4 ± 15.8). When the GSM was less than 25, the absolute reduction in plaque thickness on day 1 post-PTA was 3.3 ± 1.8 mm, in contrast to 1.8 ± 1.6 mm when GSM was more than 25 ( P < .03). The restenosis rate (PSVR more than 2) was 41% at 6 months and remained unchanged at 1 year. When the GSM was less than 25, restenosis occurred in 11% of lesions, in comparison with 78% when the GSM was more than 25 ( P < .001). Conclusion: Plaque echodensity can be used to evaluate stenoses before PTA, to predict initial success and identify a subgroup that has a high prevalence of restenosis. The identification of a group at “high-risk” of restenosis can improve the selection of patients for the procedure and also be used in prospective studies on the prevention of restenosis. (J Vasc Surg 1999;29:110-21.)

Complications in percutaneous transluminal angioplasty: relationships with patient age

Five hundred consecutive attempted lower limb angioplasties for ischaemic disease (370 patients, mean age 65.6 years, range 33-91 years) were reviewed. Significant complications occurred in 44 cases (8.8%). Nine patients (1.8%) underwent emergency surgery related to a complication. A further 12 patients (2.4%) underwent elective surgery related to a complication. In addition, four patients died within 30 days of the procedure; one following surgery performed because of a complication of angioplasty, one following a myocardial infarction, one following severe bleeding associated with subsequent thrombolytic therapy and one during emergency surgery related to a complication of angioplasty. A correlation was found between complication rate and age. This relationship was independent of the approach to, the position of, and the severity of the treated lesion. Elderly patients are at increased risk of complication in lower limb angioplasty.