Multilevel Arterial Occlusive Disease Research Articles

Neutrophils and Neovascularization

Neovascularization (NV) via growth of collateral arteries (arteriogenesis) and capillaries, arterioles and venules (angiogenesis) becomes impaired as ischemia from vascular disease progresses [1-3]. Our hypothesis is that overcoming hemodynamic and cellular obstacles to NV would yield an effective and durable option to surgical or catheter revascularization. A novel approach has been tested clinically that seeks to restore innate NV by overcoming obstacles that arise due to the multilevel arterial occlusive disease and progenitor cell deficits characteristic of Chronic Limb‐Threatening Ischemia (CLTI) [4-7].

Can Endarterectomy Be Useful in Peripheral Arterial Occlusive Disease with Critical Limb Ischemia?

Importance of thrombendarterectomy (TEA) had declined with the advent of bypass techniques and availability of prosthetic grafts, in patients with Peripheral arterial occlusive disease (PAOD). Recently, there had been a significant shift towards lower limb revascularization using endoluminal techniques. However, previously available data evaluating the long leg bypass or combined endoluminal and bypass procedures have been too anatomically heterogeneous to be easily applied to patients with infrainguinal disease and tissue loss. Clinical decision making in Complex multilevel or diffuse peripheral arterial occlusive disease with multiple co-morbidities especially associated coronary arterial disease is challenging. We describe twelve patients of iliofemoral arterial occlusive disease with tibiopopliteal arterial occlusive disease along with multiple co-morbidities like coronary arterial disease and diabetes mellitus who showed marked improvement with minimal post-operative morbidities after iliofemoral or ileopopliteal bypass grafting with endarterectomy of the tibiopopliteal segment and related review of the literature.

A clinical case of hybrid treatment of a patient with multilevel arterial occlusive disease in lower limb arteries

Treatment of patients with multilevel arterial occlusive disease in lower limb arteries is one of the challenges in vascular surgery. The need in blood flow restoration in several arterial segments usually leads to the problem of choosing a surgical procedure. Open surgery of several arterial segments is linked with a high risk of intraoperative complications, while endovascular procedures are not always possible, especially with long lesions. In such cases, hybrid surgery turns out to be a method of choice. We report the case of 50-year old patient with complaints of the right lower limb pain at rest, trophic ulcers in the right foot. The medical record showed 5-year claudification, with a gradual decrease in painless walking distance. In 2017, he underwent right common iliac artery stenting without a positive effect. Upon admission, occlusion of the right external iliac artery and superficial femoral artery was identified. After additional examination, crossing of lesions, balloon angioplasty and stenting of aorto-iliac and femoral-popliteal segments were successfully performed. The presented clinical case demonstrates high effectiveness in combination of open and endovascular procedures, while treating multilevel arterial occlusive disease. Hybrid surgical procedures allow to reduce traumatism, risk of postoperative complications and length of in-hospital stay. The main advantages and disadvantages of current surgical methods for treatment of multilevel aorto-iliac-femoral lesions are discussed. Performing hybrid surgical procedures is possible only with an experienced vascular team and in specialized hybrid operating room.Received 3 August 2018. Revised 26 November 2018. Accepted 30 November 2018.Informed consent: The patient’s informed consent to use his records for medical purposes is obtained.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Efficacy of iliac inflow repair in patients with concomitant iliac and superficial femoral artery occlusive disease

In multilevel arterial disease, whether complete revascularization or staged runoff repair should be performed remains controversial. The aim of this study was to evaluate the efficacy of iliac inflow repair and to identify clinical conditions that are associated with the need for runoff repair in concomitant iliac and superficial femoral artery (SFA) occlusive disease. Patients undergoing inflow repair for complicated flow-limiting iliac lesions with diffuse SFA disease between 2007 and 2013 were retrospectively reviewed. Patients with poor response to inflow repair underwent infrainguinal revascularization (IIR). The 29 ischemic limbs examined in this study represent 26 different patients (22 males; mean age, 77±8years). Indications for inflow repair were Rutherford Classifications III (31%), IV (31%), V (31%), and VI (7%). Severity of the complicated SFA disease was either TASC (TransAtlantic Inter-Society Consensus) type C (14%) or type D (86%). Overall, freedom from IIR was 90% after 30days and 83% after 1year. Patients having claudication, rest pain, and shallow ischemic ulcers experienced the relief of symptoms, whereas patients with deep gangrene that needed minor amputation required IIR more frequently (p<0.01). Anatomical risk factors for poor response to inflow repair were poor quality of the deep femoral artery (p<0.01) and the flow-limiting popliteal artery (p=0.02), and poor below-knee runoff (≤ 1 vessel, p<0.01). Iliac inflow repair can reverse the symptoms in patients with multilevel arterial occlusive disease that are not associated with gangrenous toes.

Hybrid Interventions in Limb Salvage

Hybrid interventions have become an integral part of our strategy for limb salvage in patients with multilevel arterial occlusive disease. In this article, we describe the commonly used hybrid interventions and review their indications and outcomes. Iliac stenting and femoral endarterectomy are the two most frequently performed procedures in hybrid cases. Short- and long-term outcomes of hybrid interventions are at least comparable to conventional endovascular and surgical revascularization procedures. Hybrid revascularization offers the efficiency and convenience of a single-stage revascularization.

Combined Percutaneous Endovascular Iliac Angioplasty and Infrainguinal Surgical Revascularization for Chronic Lower Extremity Ischemia: Preliminary Result

The purpose of this study was to evaluate the efficacy of combined ipsilateral percutaneous iliac angioplasty and open infrainguinal surgical techniques for the treatment of patients with multilevel arterial occlusive disease. Combining two types of approaches in the peripheral vascular field is a less aggressive technique and may result in excellent early patency and limb salvage rates. We report our initial experience with a combined percutaneous endovascular iliac angioplasty and infrainguinal surgical reconstruction for patients with chronic lower extremity ischemia associated with multilevel arterial occlusive disease who presented with severe (disabling) lower limb claudication that significantly reduced quality of life, as well as patients with rest pain, nonhealing ulcers, and gangrene.There were 30 patients, 20 of whom had percutaneous transluminal angioplasty (PTA) only and 10 who had PTA with a stent. The infrainguinal procedures associated with each were thromboendarterectomy with vein patch angioplasty of both the common femoral artery (CFA) (12 patients), and the popliteal artery (8 patients) and a short femoropopliteal bypass for the superficial femoral artery (SFA) after recanalization of the arterial lumen using thromboendarterectomy to shorten the bypass graft (10 patients), using a reversed saphenous vein graft. The procedures were performed from July 2007 to February 2008 at the Division of Vascular and Endovascular Surgery, Al-Hussein University Hospital (Al-Azhar Faculty of Medicine, Cairo, Egypt).The study included 30 patients, 17 males and 13 females, with a mean age of 54 years (range 42-72) who underwent both combined ipsilateral percutaneous endovascular iliac angioplasty and open surgical treatment of both femoral (ie, the CFA or the SFA) and popliteal occlusive diseases. Indications were claudication that reduced quality of life after failure of conservative medical treatment in 14 patients (46.6%), critical limb ischemia in 8 patients (26.7%), and tissue loss, nonhealing ulcers, and gangrene in 8 patients (26.7%). Initial technical and hemodynamic success was achieved in 100% of cases. Clinical success was achieved in 96.7% of cases after 6 months, and clinical failure was observed in 3.3% of cases owing to occlusion of the short femoropopliteal bypass graft. Good hemodynamic results were observed in 74.9% of cases as the mean postoperative ankle-brachial index remained elevated to 1.03 +/- 0.1 and 1.07 +/- 0.12 after 3 and 6 months, respectively.Combined vascular therapy may be used effectively in patients with chronic extremity ischemia owing to multiple levels of arterial occlusion and should be performed with good results. Technical success and early patency rates are excellent. The patients' symptoms improved and resistant ischemic ulcers healed within a short period of time.

Results of Simultaneous Hybrid Operation in Multi-level Arterial Occlusive Disease

Purpose: Hybrid procedure in lower extremity arterial disease is composed of open bypass and endovascular treatment. For proximal inflow bypass operations for distal lesions used to be performed 1 or 2 weeks after endovascular therapy. Since Aug 2005, all hybrid operations have been performed simultaneously in the operation room in our center. In this study, we compared the results of the staged hybrid operations with those of simultaneous procedures. Methods: From Jan 1999 to Dec 2009, 115 endovascular treatments and 139 bypass operations were performed. 44 bypasses were performed 1 day to 14 days after angioplasty in inflow lesions (group I) and 95 bypasses were performed simultaneously in the operation room with mobile fluoroscopy (group II). In both groups, inflow procedures included 3 femoral balloon angioplasties, 3 femoral stents, 24 iliac balloon angioplasties and 85 iliac stents. Bypass operations were composed of 39 femorofemoral and 102 infrainguinal bypasses including 60 femoropopliteal and 42 other bypasses. Results: The 3-year patency rate of bypass graft is 71.5%. There is no difference in either group. But in endovascular treatment lesion, the 3-year patency rate is 80% and that of the simultaneous group is higher than that of the staged group (P

Response to Letter Regarding Article, “Different Calculations of Ankle Brachial Index and Their Impact on Cardiovascular Risk Prediction”

We thank Jaquinandi et al for their interest in our publication. We want to stress that the patient population of the AtheroGene study is not comparable with the patient populations reported in the articles from Lee et al and Kreitner et al, which included only patients with known advanced peripheral arterial disease.1,2 The AtheroGene study includes primarily patients with coronary artery disease, no patient had rest pain or peripheral ulcers and only 52 patients (6.3%) had intermittent claudication.3 In addition, …

Criteria from intra-arterial femoral artery pressure measurements combined with reactive hyperaemia to assess the aorto-iliac segment; A prospective study

Direct femoral artery blood pressure measurements combined with reactive hyperaemia (FAP study) were performed on 50 extremities (45 patients) with multilevel arterial occlusive disease of the lower extremities. In a previous retrospective study we established criteria for detection of significant aorto-iliac occlusive disease. These criteria were used in a prospective way in this study. Twenty-seven extremities were subjected to a proximal and 23 extremities to a distal reconstruction. The half-year postoperative results were evaluated. The criteria used were 86 per cent sensitive, 100 per cent specific and 93 per cent accurate in relation to predicting the postoperative haemodynamic result. The positive predictive value was 100 per cent and the negative predictive value 89 per cent. The criteria are presented and compared with data from the literature. It is concluded that FAP studies are a simple and excellent way to assess the aorto-iliac segment and to predict the outcome of a reconstruction in multilevel arterial occlusive disease.

Evaluation of patients with peripheral vascular disease

Approximately 10% of people age >55 years have asymptomatic peripheral atherosclerotic disease (PAD), 5% have intermittent claudication (IC, the cardinal symptom), and 1% critical leg ischemia (rest pain or gangrene). In patients with IC, worsening occurs in ∼16%, bypass surgery is required in ∼7%, and amputation in ∼4%. Disease progresses more frequently in diabetics and in tobacco smokers. Patients with PAD suffer increased cardiovascular morbidity related mainly to coronary artery disease with a mortality rate of approximately 30% after 5 years. Compared to patients without PAD, the relative risk of coronary death is approximately 6.6, overall cardiovascular mortality 5.9, and all-cause mortality 3.1. Pain at rest or ischemic gangrene indicates severe, often multilevel arterial occlusive disease and calls for aggressive management, which usually includes angiography and revascularization by percutaneous angioplasty or surgery. Critical limb ischemia results in some 150,000 amputations annually in the U.S., with perioperative mortality rates of 5-10% for below-knee and up to 50% for above-knee amputation because of comorbidities. Physical findings include trophic signs of ischemia, vascular bruits and peripheral pulse deficits. Ischemic ulcers usually involve the tips of the toes or the heel of the foot, and are typically painful on elevation and most bothersome at night. Ancillary diagnostic modalities begin with the ankle/arm systolic pressure index (ABI); a value <0.90 indicates PAD with significant prognostic implications. More precise assessment in the noninvasive vascular laboratory may involve a combination of segmental limb pressure measurements and pulse volume waveform recording, which is over 90% accurate for predicting the level and extent of PAD. Exercise testing enhances the value of these observations. Magnetic resonance imaging methods are emerging to characterize the arterial wall and atherosclerotic lesions. The diagnosis of PAD does not generally require invasive techniques, and most patients with IC do not need contrast angiography. Angiography is indicated for mapping of the extent and location of arterial pathology prior to revascularization.

The impact of diabetes on arterial reconstructions for multilevel arterial occlusive disease

Purpose: Critical limb ischemia due to multilevel arterial occlusive disease often may be treated with an inflow procedure alone; however, a subset patients require a subsequent infrainguinal revascularization for persistence of their symptoms. As diabetic patients typically exhibit a pattern of extensive distal arterial disease, we sought to determine if the presence of diabetes mellitus altered the need for an outflow procedure after inflow bypass. Methods: A total of 504 patients undergoing inflow bypass for occlusive disease and lower extremity ischemia between 1990 and 1998 were entered prospectively into a computerized vascular registry. Inflow bypass procedures performed were as follows: aortofemoral (370; 73%), axillofemoral (56; 11%), femorofemoral (81; 16%). Of these patients, 79 required subsequent outflow bypass for unresolved ischemic symptoms. Multiple logistic regression analysis was used to analyze the effects of diabetes and multiple other risk factors on the need for an additional outflow procedure. Results: The indications for surgery were limb salvage (78%) and disabling claudication (22%). Overall morbidity was 17.7% (hematoma, 3.8%; wound infection, 2.5%; graft occlusion, 1.3%; myocardial infarction, 2.5%; acute renal failure,1.3%; pulmonary failure, 2.5%; pneumonia, 3.8%). Overall mortality was 0%. Diabetic patients comprised a greater proportion of the total number of patients requiring inflow bypass (301 of 504) as well as a greater proportion of patients requiring inflow and outflow procedures (47 of 79). Diabetes was determined not to be an independent risk factor for the need for multiple revascularization procedures by multiple logistic regression analysis ( P >0.10). Conclusion: Although patients with diabetes are predisposed to the development of distal arterial occlusive disease, in this study the subgroup of diabetic patients who present with aortoiliac occlusive disease were no more likely than patients without diabetes to require multiple levels of revascularization. These findings provide little rationale for simultaneous inflow and outflow procedures based on the presence of diabetes alone.

Combined Iliac Angioplasty and Infrainguinal Revascularization Surgery Are Effective in Diabetic Patients with Multilevel Arterial Disease

The success of percutaneous transluminal angioplasty (PTA) in the treatment of common and external iliac atherosclerotic lesions has been established for the general population. However, several studies have suggested that the presence of diabetes may reduce the effectiveness of iliac angioplasty, particularly in the setting of limb-threatening ischemia requiring concomitant lower extremity revascularization. This study compared the results of iliac artery PTA performed in conjunction with infrainguinal bypass for limb-threatening ischemia for diabetic (DM) and nondiabetic (non-DM) patients. Between 1991 and 2000, 159 PTA were performed in 126 patients (DM = 99/79%, non-DM = 27/21%) in conjunction with subsequent infrainguinal bypass for limb-threatening ischemia (gangrene = 42%, ulcer = 36%, rest pain = 22%). These patients were followed prospectively using a computerized vascular registry. Stents were placed in 34 (21.4%) cases for suboptimal angioplasty results. In this study the combined use of standard surgical and endoluminal modalities for the treatment of multilevel arterial occlusive disease resulted in excellent cumulative patency and limb salvage rates. The presence of diabetes did not alter these favorable results. Multimodal vascular therapy may be used effectively in diabetic patients with limb-threatening ischemia due to multiple levels of arterial occlusion.

Review of the assessment of single level and multilevel arterial occlusive disease in lower limbs by duplex ultrasound

The purpose of this article is to review the performance of duplex ultrasound scanning in assessing lower limb arterial disease with emphasis on patients with multisegmental occlusive lesions. Several studies have reported that duplex scanning can be as accurate as angiography to localize arterial stenoses. In spite of these promising results, there still remain some difficulties and controversies. Among them, it has been reported that multisegmental disease may affect the accuracy of duplex scanning. Indeed, some studies have indicated a lower sensitivity for detecting significant stenoses distal to severe or total occlusions. It also was demonstrated that second-order stenoses were detected with lower sensitivity compared to first-order stenoses. The main reason proposed to explain this lower sensitivity is that the highly reduced flow distal to occluded or highly stenotic segments increases the difficulty of detecting significant Doppler velocity changes in the distal or secondary stenoses. The intrinsic limitations of the peak systolic velocity ratio used as a classification criterion are presented. Finally, new and promising developments in power Doppler imaging and ultrasound contrast agents are discussed, because they may allow expansion of the capabilities of current ultrasound scanning systems and provide more accurate diagnosis of patients with multiple disease.

Endovascular repair of aortoiliac occlusive disease.

Occlusive disease of the aorta and iliac and femoral arteries may lead to limb-threatening ischemia when multiple levels of disease are present. The combined treatment of severe aortoiliac and infrainguinal disease using standard techniques may be hazardous or contraindicated in patients with multiple, previous reconstructions or severe co-morbid medical illnesses. This report summarizes the technical feasibility and early results of aortoiliac endovascular stented grafts (ESGs) in combination with conventional surgical reconstructions for the treatment of multilevel arterial occlusive disease. Forty-two patients with multilevel aortoiliofemoral limb-threatening occlusive disease had an ESG inserted to treat long-segment, multilevel, occlusive disease. ESGs originated from either the aorta or the common iliac artery and were inserted into one of the femoral arteries. ESG lengths ranged from 16 to 30 cm (mean 21 cm). Conventional surgical bypasses were constructed, when necessary, from polytetrafluoroethylene (PTFE) or saphenous vein and were extended using standard techniques to the popliteal, tibial, or contralateral femoral arteries. Technical success of graft insertion was achieved in 39 of 42 attempted ESG procedures (93%). The 18-month primary and secondary cumulative patency rates for ESGs were 89 +/- 9 (SE) and 100%, respectively. Limb salvage was achieved in 94% of patients at 24 months. Four patients had minor postprocedure complications (10%), and there was one death. Endovascular aortoiliac grafts, often in combination with conventional surgical infrainguinal bypasses, are a technically feasible, potentially safe option for the treatment of limb-threatening aortoiliofemoral occlusive disease and have demonstrated encouraging early patency. Long-term follow-up is necessary before widespread application of this technique is instituted.

Sequential Aortofemoropopliteal/Distal Bypass for Treatment of Critical Lower-Limb Ischaemia

Multilevel arterial occlusive disease is often the main cause of critical ischaemia of the lower limb. The aim of this study was to determine the diagnostic criteria that could help select patients for sequential aortofemoropopliteal/distal reconstruction and to compare the results after simultaneous and two-stage surgery. Some 1953 aortofemoral reconstructions were performed during a 6-year period (1987-1992). In 245 cases (12.5%) sequential aortofemorodistal (popliteal or tibial) procedures were performed for critical limb ischaemia Fontaine classification grade III and IV. Two-segment reconstructions were performed in one stage in 161 cases (group A), and two separate operations were performed, the outflow procedure usually following within 12 months after inflow surgery, in 84 cases (group B). The perioperative mortality rates were 3.2% in group A (five deaths) and 5.9% in group B (five deaths). Limb salvage rates were 95.6% at 1 year and 90.4% at 5 years for group A and 88.8% at 1 year and 80.0% at 5 years for group B. Primary inflow bypass patency rates were 97.7% at 1 year and 91.3% at 5 years for group A and 93.4% at 1 year and 76.3% at 5 years for group B, while secondary inflow bypass patency rates were 98.8% at 1 and 5 years for group A, and 95.3% and 88.3% at 1 and five years respectively for group B. Primary outflow bypass patency rates were 91.4% at 1 year and 65.5% at 5 years for group A, and 84.9% at 1 year and 59.4% at 5 years for group B. Secondary outflow bypass patency rates were 92.2% at 1 year and 81.8% at 5 years for group A, and 86.1% at 1 year and 65.9% at 5 years for group B. The data demonstrate that single-stage multisegment reconstruction for multilevel arterial occlusive disease is a safe and effective method of treating critical limb ischaemia.

Sequential aortofemoropopliteal/distal bypass for treatment of critical lower-limb ischaemia

Multilevel arterial occlusive disease is often the main cause of critical ischaemia of the lower limb. The aim of this study was to determine the diagnostic criteria that could help select patients for sequential aortofemoropopliteal/distal reconstruction and to compare the results after simultaneous and two-stage surgery. Some 1953 aortofemoral reconstructions were performed during a 6-year period (1987–1992). In 245 cases (12.5%) sequential aortofemorodistal (popliteal or tibial) procedures were performed for critical limb ischaemia Fontaine classification grade III and IV. Two-segment reconstructions were performed in one stage in 161 cases (group A), and two separate operations were performed, the outflow procedure usually following within 12 months after inflow surgery, in 84 cases (group B). The perioperative mortality rates were 3.2% in group A (five deaths) and 5.9% in group B (five deaths). Limb salvage rates were 95.6% at 1 year and 90.4% at 5 years for group A and 88.8% at 1 year and 80.0% at 5 years for group B. Primary inflow bypass patency rates were 97.7% at 1 year and 91.3% at 5 years for group A and 93.4% at 1 year and 76.3% at 5 years for group B. while secondary inflow bypass patency rates were 98.8% at 1 and 5 years for group A, and 95.3% and 88.3% at 1 and five years respectively for group B. Primary outflow bypass patency rates were 91.4% at 1 year and 65.5% at 5 years for group A, and 84.9% at 1 year and 59.4% at 5 years for group B. Secondary outflow bypass patency rates were 92.2% at 1 year and 81.8% at 5 years for group A, and 86.1% at 1 year and 65.9% at 5 years for group B. The data demonstrate that single-stage multisegment reconstruction for multilevel arterial occlusive disease is a safe and effective method of treating critical limb ischaemia.

Limb-threatening ischemia due to multilevel arterial occlusive disease. Simultaneous or staged inflow/outflow revascularization.

Limb-threatening ischemia due to severe multilevel arterial occlusive disease may require both inflow and outflow bypass to achieve limb salvage. Simultaneous inflow/outflow bypass has been advocated because the cumulative risks of separate staged inflow/outflow procedures can be avoided. However, the magnitude of complete revascularization is substantial; thus, the morbidity and mortality of simultaneous inflow/outflow bypass may be excessive. The medical records of 450 patients undergoing lower extremity arterial reconstruction between 1988 and 1994 were retrospectively reviewed, allowing identification of 54 patients who had undergone simultaneous aortoiliac and infrainguinal bypasses. This group consisted of 38 men and 26 women (mean age: 64.7 years), with significant cardiac disease in 24, smoking history in 53, and diabetes mellitus in 15. Indications for surgery were limb-threatening ischemia in 48 (89%) and severe short-distance claudication in 6 (11%). Inflow disease was corrected by direct aortoiliac reconstruction in 28, whereas other extra-anatomic bypasses were constructed in 26. Outflow revascularization required infrainguinal bypass to the infragenicular arteries in 46 (below-knee popliteal: 21; tibial: 25), a concomitant profundaplasty in 26, and a composite bypass conduit in 14. Limb salvage was 97% at 30 days whereas morbidity/mortality were 61% and 19%, respectively. However, the majority of complications and deaths occurred in patients undergoing aortic inflow plus complex outflow procedures (profundaplasty and/or composite bypass conduits), in which the morbidity/mortality rates were 84.2% and 47.4%, respectively, compared with rates of 45.7% and 2.9% (p < 0.01) after all other inflow/outflow procedures. The increased difficulty of these complex procedures is reflected in the significantly greater blood loss and operative times (1853 mL and 10.0 hours) compared with similar values (1125 mL and 7.7 hours)(p < 0.01) for all other inflow/outflow procedures. Simultaneous inflow/outflow bypasses are effective and safe in patients with severe, multilevel arterial occlusive disease, except when a complex outflow procedure is needed in conjunction with direct aortoiliac reconstruction. In the latter setting, a staged procedure is recommended because it may be associated with less morbidity and mortality.

Long-term follow-up of patients having infrainguinal bypass performed below stenotic but hemodynamically normal aortoiliac vessels

Because infrainguinal bypasses performed on the basis of normal papaverine testing in patients with multilevel arterial occlusive disease are done below arteriographically diseased although hemodynamically normal vessels, there is concern about progression of suprainguinal disease compromising long-term success. This study has been done to assess the long-term results of such bypasses. Between 1979 and 1985, infrainguinal bypasses selected by papaverine testing were done on 92 limbs having hemodynamically normal inflow in the presence of arteriographically demonstrable aortoiliac stenoses of 15% to 70%. Long-term hemodynamic and clinical success rates were determined with criteria based on papaverine and noninvasive vascular testing. There was no significant difference in hemodynamic success at 48 months (by life-table analysis) (p = 0.98) when comparing limbs with less than 50% aortoiliac stenoses to limbs having 50% or greater stenoses. The difference between the mean degree of preoperative inflow stenoses for long-term hemodynamic successes (32.5% ± 1.5%) and failures (34.6% ± 3.0%) was not significant (p = 0.57). There was no significant difference (p = 0.98) in the number of subsequent inflow procedures required in limbs with preoperative aortoiliac stenoses of less than 50% (13.5%) vs. aortoiliac stenoses of 50% or greater (13.3%). Long-term results of infrainguinal bypass done below stenotic but hemodynamically normal aortoiliac vessels are not related to the amount of angiographically demonstrable inflow stenosis. Selection of patients for infrainguinal bypass on the basis of papaverine testing, irrespective of angiographic findings, eliminates unnecessary inflow procedures without detriment to long-term success.

Aortofemoral or femoropopliteal revascularization? A prospective evaluation of the papaverine test

Proper selection of suprainguinal vs. infrainguinal arterial revascularization in patients with multilevel disease requires hemodynamic assessment. In such patients hemodynamic evaluation of the aortoiliac system cannot be made accurately with either arteriography or current noninvasive techniques. One hundred six lower extremities underwent preoperative triplane arteriography, measurement of Doppler-derived segmental blood pressures, measurement of common femoral intra-arterial pressure, and intra-arterial injection (30 mg) of the vasodilator papaverine hydrochloride prior to arterial bypass. Common femoral intra-arterial pressure was monitored continuously before and after papaverine injection. The resting femoral/brachial pressure index (FBI) and the maximum change in this index (%ΔFBI) following papaverine injection were calculated. To be considered improved postoperatively, claudicants required an increase in treadmill walking time of ≥50%, whereas patients operated on for limb salvage required an increase in the thigh/brachial pressure index (TBI) of ≥0.15 for suprainguinal revascularizations and an increase of TBI to ≥0.9 for infrainguinal revascularizations. In the first 41 extremities (phase I), receiver operator characteristic analysis revealed a %ΔFBI ≥ 15% to be optimal in the detection of hemodynamically significant aortoiliac disease. In phase II (65 limbs) this discriminant value for %ΔFBI was assessed prospectively. In phase I, in which the choice of supra- vs. infrainguinal bypass was determined arteriographically, only 80% of the extremities were improved; in phase II, in which supra- vs. infrainguinal bypass was determined by the papaverine test, 98% of extremities were improved (p < 0.01). Hemodynamic testing by pharmacologic vasodilation is superior to both triplane arteriography and resting hemodynamic measurements and is highly accurate in the selection of proper bypass procedures in patients with multilevel arterial occlusive disease.

The effect of sensing site on the limb segmental blood pressure determination.

The effect of the sensing site on upper-thigh blood pressure readings was studied. We used a multisensing mercury strain gauge (MSG) plethysmographic method and Doppler ultrasound to monitor the upper-thigh blood pressure from the posterior tibial artery and compared the results with those from the popliteal artery. Upper-thigh pressures were measured in 30 limbs of 15 normal subjects and in 60 limbs of 35 patients with multilevel peripheral arterial occlusive disease. Upper-thigh pressures sensed from a thigh MSG placed just distally to the pressure cuff and monitored by the popliteal artery Doppler probe were significantly higher than the upper-thigh pressure readings obtained from an MSG placed on the calf or toe and monitored by a posterior tibial artery Doppler probe in patients with multilevel arterial lesions. In the control group, no significant pressure differences were found. The importance of placing the sensor (MSG or Doppler probe) close to the pressure cuff is critical to obtain accurate thigh pressures in patients with multilevel arterial occlusive disease. Otherwise, erroneous diagnoses, such as nonexistent aortiliac or common femoral artery stenosis, may be made.