Transluminal Angioplasty Research Articles

Infected Renal Artery Pseudoaneurysm and Mycotic Aortic Aneurysm After Percutaneous Transluminal Renal Artery Angioplasty and Stent Placement in a Patient With a Solitary Kidney

Endovascular infections after percutaneous transluminal renal angioplasty with stenting (PTRAS) are rarely reported. Because strict longitudinal follow-up of patients undergoing PTRAS is lacking, the true incidence of such complications remains obscure. We report the first case of a patient with an infected renal artery pseudoaneurysm and de novo mycotic aortic aneurysm after PTRAS. This case serves to illustrate several important points, including (1) the retrieval of renal function in patients with renal artery occlusion, (2) the pathogenesis of infection after PTRAS, (3) the diagnosis and management of endovascular infection after percutaneous vascular intervention, and (4) recommendations for periprocedural antibiotic prophylaxis during PTRAS.

Infected Renal Artery Pseudoaneurysm and Mycotic Aortic Aneurysm After Percutaneous Transluminal Renal Artery Angioplasty and Stent Placement in a Patient With a Solitary Kidney

Infected Renal Artery Pseudoaneurysm and Mycotic Aortic Aneurysm After Percutaneous Transluminal Renal Artery Angioplasty and Stent Placement in a Patient With a Solitary Kidney

The Endovascular Management of Blue Finger Syndrome

Objectives: to review our experience of the endovascular management of upper limb embolisation secondary to an ipsilateral proximal arterial lesion.Design:a retrospective study.Materials and methods:over 3 years, 17 patients presented with blue fingers secondary to an ipsilateral proximal vascular lesion. These have been managed using transluminal angioplasty (14) and arterial stenting (five), combined with embolectomy (two) and anticoagulation (three)/anti-platelet therapy (14).Results:all the patients were treated successfully. There have been no further symptomatic embolic episodes originating from any of the treated lesions, and no surgical amputations. Complications were associated with the use of brachial arteriotomy for vascular access.Conclusions:endovascular techniques are safe and effective in the management of upper limb embolic phenomena associated with an ipsilateral proximal focal vascular lesion.

Síndrome de hiperperfusión como complicación de la angioplastia transluminal percutánea de la arteria carótida interna

The hyperperfusion syndrome (HS) is described as an infrequent complication of carotid endarterectomy. It may also occur in percutaneous transluminal carotid angioplasty with a similar causal mechanism and clinical features to those seen in HS related to carotid endarterectomy. We describe the case of a 69 year old man who developed HS at the time of transluminal carotid angioplasty and 'stenting' of symptomatic, pre-occlusive stenosis of the left internal carotid artery. This complication was not detected on the postoperative arteriography. On CT the presence of a hemispheric hematoma was confirmed. It is thought that HS is caused by a fault in autoregulation of the cerebral blood flow following correction of vascular stenosis in previously ischemic territory. Most of the early complications of transluminal carotid angioplasty are ischemic. HS is rare but is a possible complication of transluminal carotid angioplasty and therefore meticulous control of the blood pressure is necessary. A CT scan after any atypical complication of angioplasty may be considered to be essential.

Five-Years' Experience with Revision of Failing Peripheral Vein Bypasses

The aim of this study was to assess the results of surgical and endovascular treatment of failing or failed infrainguinal vein bypasses. Eight hundred seventy-five patients with peripheral vein bypasses performed during a 5-year period were followed up prospectively by ankle blood pressure measurements and/or duplex scanning at 3, 6, 9, 12, 18, 24, 36, and 48 months. A total of 59 (7%) grafts required revision during the study period. Fifty-six juxtaanastomotic or intragraft stenoses in 46 failing but patent bypasses were electively revised. Thirty-one predominantly proximal and midgraft lesions in 28 grafts were treated surgically by patch angioplasty (n= 17), interposition/jump grafting (n= 10), or thromboendarterectomy (n= 4). Twenty-five predominantly distal stenoses in 18 grafts were treated by percutaneous transluminal balloon angioplasty (PTA). With this approach, surgery yielded a higher 12-month “primary” bypass patency after revision (72% vs 37%, P=0.02), a higher secondary patency (81% vs 48%, P=0.05) and a better limb survival (96% vs 64%, P=0.03) than PTA. Following thrombectomy (n=12) or thrombolysis (n= 1) of 13 occluded bypasses, a 6-month “primary” patency after revision of 31%, a secondary patency of 38%, and a limb survival of 61% were achieved. In conclusion surgical repair appears to be the most durable procedure in the management of threatened infrainguinal vein bypasses. PTA of distal vein graft lesions was associated with a high risk of restenosis and graft failure.

Aortoiliac Reconstruction and Kidney Transplantation: A Multicenter Study

The occurrence of aortoiliac lesions with renal transplantation is an increasingly common combination that causes problems regarding operative strategy and indications for aortoiliac reconstruction and renal transplantation. To gain greater insight into these problems we undertook a retrospective multicenter study based on data from 24 kidney transplantation centers in France. A total of 83 patients who underwent both aortoiliac reconstruction and kidney transplantation were enrolled. Patients were divided into two groups according to the order in which the two procedures were performed. Group I included 36 patients in whom aortoiliac reconstruction was performed before kidney transplantation-either during the same procedure (6 patients) or as separate procedures (30 patients). Group II included 47 patients in whom aortoiliac reconstruction was performed after kidney transplantation. The mean age was 49.9 years. There were 43 abdominal aortic aneurysms (51.8%), 36 occlusive aortoiliac lesions (43.4%), and 4 aortoiliac dissections (4.8%). Prosthetic bypass grafting was performed in 72 cases (86.8%), transluminal angioplasty in 6 cases (7.2%), endarterectomy in 3 cases (3.6%), and arterial autograft bypass in 1 case. Renal transplant protection was used during aortoiliac clamping in only 3 patients in group II (7.3%). One month after the second procedure (i.e., kidney transplantation in group I and aortoiliac reconstruction in group II), creatinemia was <200 micromol/L in 27 patients (87.1%) in group I and in 37 patients (88.1%) in group II. The graft survival rate was 86.1% in group I and 89.3% in group II. The overall postoperative morbidity rate was 36.1% (13 cases) in group I and 36.1% (17 cases) in group II. One year after the second procedure creatinemia was <200 micromol/L in 29 patients (93.5%) in group I and 36 patients (93%) in group II. The graft survival rate was 86.1% in group I and 85.1% in group II. The outcome of kidney transplantation is comparable regardless of whether the procedure is performed alone or in association with aortoiliac reconstruction. This finding indicates that kidney transplantation should be performed in patients presenting indications for prior aortoiliac reconstruction. The outcome of aortoiliac reconstruction without graft protection in kidney transplant patients is comparable to the outcome of conventional aortoiliac reconstruction in patients with native kidneys.

Percutaneous transluminal bilateral renal artery angioplasty in patients with bilateral renal artery stenosis

Percutaneous transluminal bilateral renal artery angioplasty in patients with bilateral renal artery stenosis

Experimental study of Hirudo andSalvia miltiorrhiza on smooth muscle cell hyperplasia following balloon angioplasty

To find the preventive method of restenosis after transluminal angioplasty (TA). Sixty rabbit iliac arteries of 30 rabbits were divided randomly into three groups, group A, B and C, 20 in each. After experimental atherosclerotic stenosis and TA performing, ordinary forage plus 2 g of hirudo powder was fed to the group A every day, to the group B, 2 g Salvia miltiorrhiza powder was added and to the group C, ordinary forage only. Angiography and pathomorphological examination were carried out 30 days later. (1) Hirudo significantly reduced the thickness of iliac intima as compared with the other two groups (P < 0.05), the thickness in the group A, B and C was 40.1 +/- 9.8 microns, 48.2 +/- 8.2 microns and 69.3 +/- 9.2 microns respectively. (2) The incidence of restenosis after TA in both group A (31.4%) and group B (48.4%) were significantly lower than that in the group C (62.8%, P < 0.05). And significant difference was also found in comparison of group A and group B (P < 0.05). (3) Ultrastructure change examined by transmission electron microscopy showed that less rough endoplasmic reticulum and more myofilaments in well differentiated smooth muscle cell (SMC) of the arterial intima in the group A and B, while in the group C, more rough endoplasmic reticulum, more synthetic cells were seen in SMC. Hirudo and red sage root could effectively inhibit the hyperplasia of SMC in arterial intima and reduce the intima thickness and the incidence of restenosis after TA significantly, thus might play a role in the prevention of restenosis after TA. The effect of hirudo is more potent than that of red sage root.

Cerebral Vasospasm

Despite advances in diagnosis and therapy, cerebral vasospasm after subarachnoid hemorrhage remains the greatest treatable cause of morbidity and mortality in patients who survive the initial hemorrhage. Clinical features of vasospasm depend upon the severity and location of the arterial narrowing, age and clinical condition of the patient, the presence of other complication factors, and the extent of collateral circulation to the ischemic brain. The diagnosis of vasospasm is largely clinical, although awareness of predisposing factors (e.g. amount of subarachnoid blood on CT scan) and noninvasive transcranial Doppler monitoring may augment the clinical diagnosis. Treatment is generally palliative, including volume expansion, calcium channel blocking agents, and transluminal angioplasty. Research in experimental models of vasospasm has implicated several factors in the pathogenesis of chronic arterial narrowing, including oxyhemoglobin from lysing erythrocytes, lipid peroxidation, and endodthelin.

Thrombolysis enters the race

Thrombolysis has been shown to be an effective treatment for ischaemic stroke. The major obstacles to more widespread use of this therapy are lack of awareness that treatment is possible and the short, less than 3 hours, therapeutic window. Even though the use of this therapy can be burdened by the occurrence of intracerebral haemorrhages, there is tantalizing evidence that thrombolysis is the only approach that has been so far demonstrated to improve the outcome of these patients. Early recognition of the onset of stroke, the immediate transfer to a suitably equipped facility and careful screening of a computed tomographic scan of the head for signs of early infarction are necessary for the safe administration of intravenous thrombolysis. There is mounting evidence that intra-arterial thrombolysis in combination with transluminal angioplasty has even a greater potential than intravenous thrombolysis and, possibly, a lower rate of intracerebral haemorrhages. Despite doubts having been raised about the use of thrombolysis in routine clinical practice, it appears that this therapy is most effective in those patients treated with careful adherence to published guidelines.

Transluminal vascular stent implantation for a patient with renovascular hypertension due to renal artery stenosis

In recent years, transluminal vascular stents have been implanted in patients with renal artery stenosis. At present, controversy remains as to whether the long-term outcome of stent implantation is better than that of percutaneous transluminal renal angioplasty (PTRA). However, until now, no clinical experience of a stent placement for renal artery stenosis has been reported in our country. We implanted a Palmaz stent in a patient with renovascular hypertenstion due to renal artery restenosis who had already undergone PTRA. The renal function and blood pressure of the patient improved remarkably.

Renovascular hypertension

Renovascular hypertension is the most common cause of secondary hypertension. Interest in identifying patients with renal artery stenosis has been stimulated recently by advances in three areas. First, is the realization that not only can renal artery stenosis cause renovascular hypertension, but it can also lead to progressive renal failure (ischemic nephropathy) caused by progression of disease, usually atherosclerotic in nature. Second, advances in percutaneous transluminal renal angioplasty and, especially, the recent use of renal stents has led to a less invasive management of these patients as compared with traditional renal revascularization. Finally, the development of newer less invasive diagnostic techniques, both for the identification of patients with renal artery stenosis and to follow patients with known renal artery stenosis, has simplified the diagnostic aspect of the disease.

Early Hemodynamic Effects of Percutaneous Transluminal Angioplasty in Superficial Femoral Artery Disease

This study was conducted to assess the early hemodynamic effects of percutaneous trans luminal angioplasty (PTA) in patients with superficial femoral artery (SFA) atheroscle rotic disease. Seventeen patients (forty-nine to eighty-five years, median sixty-seven years), underwent PTA in the SFA, except 1 who had PTA in both the SFA and popliteal artery. Fifteen patients were claudicant whereas the other one had rest pain and ulcera tion. Ten patients had localized SFA occlusion on the angiogram (3 of them had combined stenoses in the common femoral, profunda, and popliteal arteries) and 7 had localized stenoses more than 50%. Ankle-brachial index (ABI), limb blood flow (measured by air plethysmography), peak systolic velocity (PSV) ratio across the stenosis, and the spectral waveform analysis displayed by color flow duplex imaging (CFDI) were assessed before and one day after PTA. Before PTA, the median ABI and limb blood flow were 0.55 ±0.19 and 58.6 ±13.1 mL/min, respectively. The waveform in the poststenotic area of the SFA was monophasic in 5 patients and biphasic in the others, and the PSV was at least doubled in the stenotic area. PTA was technically successful in 16 patients and failed in 1 with an occluded SFA. After successful PTA the median ABI was 0.76 ±0.15 (P&lt;0.00001), and the median limb blood flow was 78.1 ±11.9 mL/min (P&lt;0.00001). The waveform in the dilated area of the SFA was biphasic in all patients with marked decrease in the PSV and forward diastolic velocity present. Postangioplasty pain-free walking distance was at least doubled in 12 patients. In the case of the failed PTA the ABI, limb blood flow, poststenotic waveform, PSV, and pain-free walking-distance were unchanged. In conclusion, early improvement in the hemodynamic parameters occurs over the first day after a successful PTA. These hemodynamic parameters correlate well with the findings of the postangioplasty angiogram and thus can be used in the follow-up of the patients after PTA.

Radiation-Induced Arterial Disease of the Lower Limb

We describe a case of radiation injury to the superficial femoral and upper popliteal arteries in a 39-year-old man treated 13 years earlier for an osteosarcoma of the right femur. Following two failed attempts at transluminal angioplasty, a saphenous vein femoropopliteal bypass graft was performed successfully. A comprehensive review of the literature on radiation-induced arterial injury to the limbs is presented with a discussion of the different management options. Percutaneous transluminal balloon angioplasty seems to have no place in the treatment of such lesions.

Coronary vein flow velocity changes during transluminal balloon angioplasty: a study using the Doppler guide wire.

The coronary flow velocity changes in the great cardiac and middle cardiac veins, induced by intracoronary administration of nitroglycerine, adenosine, and during percutaneous transluminal coronary angioplasty, were evaluated in 12 patients with significant coronary stenoses, using the Doppler wire (Flowire). Optimal spectral signals of the time-averaged peak flow velocity were obtained in 10 patients. Nitroglycerine produced no significant flow velocity changes (P = 0.13). Adenosine caused a significant augmentation of flow velocity compared to baseline (P = 0.003). During balloon inflation, venous flow velocity decreased (P = 0.007); however, the venous outflow did not cease. A pronounced venous hyperemic response, following balloon deflation, was also documented. The utility of continuous vein flow velocity monitoring with the Flowire, during high-risk and complicated coronary interventions remains to be elucidated.

Vascular access: Principles and practice, 3rd edition

Vascular access: Principles and practice, 3rd edition Samuel Eric Wilson, St. Louis, 1996, Mosby, 312 pages, $79. This book is one of the original texts on vascular access and remains at the forefront of the field with this new edition. The panel of contributing authors has been expanded over the first two editions, and the book has been reorganized. The current edition presents the material in a more useful and practical manner than earlier editions. The current volume separates chronic venous access from hemodialysis access, and presents a discussion of types of access (catheters, ports, prosthetic grafts, native fistulas) useful in the treatment of multiple diseases. The book starts with historical development of vascular access then proceeds with basic science and patient evaluation. The middle chapters cover the multitude of procedures, and their complications, for arteriovenous and chronic and acute venous access. The final chapters discuss some new endovascular techniques and instrumentation that appear to have value, but whose precise place in the armamentarium of the vascular access surgeon is as yet undefined. Included is a chapter on peritoneal access, giving the book full coverage of dialysis access. The chapters on management of infections, thrombolysis and transluminal angioplasty, vascular access for trauma, vascular interposition for hemodialysis, and vascular access for pediatric patients are particularly thorough and well-written. The quality of drawings and sketches is adequate throughout most of the text but disappointing in the important chapter on surgical anatomy. Some chapters refer to specific brand names of products rather than generic names. The proofreading of the text was quite good, as noted by very few spelling errors, none of which impacted the clarity of the text. The reorganization of this edition has been great improvement over the previous editions, and at a retail price of $79 this book is a good value. Compared to other texts it is now the most current and comprehensive. This book should be included in the library of anyone interested in vascular access surgery.

Development of a Transfemorally Delivered Endovascular Graft for Treatment of Aortic Aneurysms in a Canine Model

Advances in the treatment of atherosclerotic disease by transluminal angioplasty and intra-arterial stenting have led to the development of a transfemoral endovascular approach to the treatment of aortic aneurysmal disease. The authors investigated this technique using an endovascular graft employing self-expanding anchors for the exclusion of infrarenal aortic aneurysms. They investigated the technique of transfemoral endovascular aortic grafting in 13 male mongrel dogs weighing an average of 30 kg. Eleven animals had fusiform infrarenal aortic aneurysm models created. One week to three months after surgery all animals underwent midstream aortography under general anesthesia to examine aneurysm morphology. A 14 French catheter was introduced through the right common femoral artery, and under fluoroscopic guidance the endovascular graft was delivered in an infrarenal aortic position. Completion aortography was then performed to confirm placement. They tested two endovascular graft prototypes. The first employed a proximal anchor attached to the graft and a separately delivered distal anchor. Successful graft delivery was achieved in five of six attempts. Unsuccessful graft delivery occurred in 1 case because of an inability to negotiate aneurysm tortuosity. After delivery graft twisting occurred in 1 case and graft invagination occurred in 2 others upon the attempt to deliver the distal anchor. Successful exclusion was achieved in 3 of 4 remaining cases with an aneurysm model using this prototype. The second prototype employing proximal and distal anchors attached to the graft was successfully deployed in seven of seven attempts. Successful aneurysm exclusion was achieved in 5 of these 7 cases. Failure to exclude the aneurysm neck occurred in 2 cases. In this preliminary study the authors found the concept of endovascular delivery of a self-anchoring tube graft to be feasible. The optimal delivery system is flexible and possesses a small outer diameter to allow a transfemoral approach through moder ately tortuous iliac arteries. Accurate delivery is aided by intermittent fluoroscopic examination. Doubly anchored grafts are necessary to ensure aneurysm exclusion and prevent graft twisting. Self expanding anchors allow simple endovascular graft deploy ment in a single pass. Continued animal investigation into the fate of aortic side branches, distal embolization, and graft migration is necessary to ensure the eventual success of this technique.

Comparison of clinical follow-up and duplex surveillance of infrainguinal vein bypasses

The evidence in support of surveillance has been principally based on the favourable primary-assisted patency of stenosed grafts following revision (60–80% at 5 years) compared with the poor secondary patency of revised occluded grafts (20–40% at 5 years). Both the capital cost and workload generated by surveillance are considerable. More information is needed on the benefits of surveillance compared with clinical follow-up. A retrospective comparison of 50 vein grafts (44 reversed, six in situ) undergoing colour-coded duplex surveillance and 50 vein grafts (46 reversed, four in situ) under clinical follow-up, with duplex scans obtained only when clinically indicated, has been performed. Four (8%) stenoses of ≥50% were identified in the surveillance group. One 50% proximal anastomotic stenosis failed to progress on sequential scans. Three stenoses were treated (one mid graft, two popliteal) by vein patch angioplasty (two cases) and transluminal angioplasty (one case). Both groups were followed-up for 12 months. Secondary patency at 12 months (88% surveillance; 80% clinical follow-up) was not significantly different ( P = 0.3). Similarly, limb salvage at 12 months (94% surveillance; 88% controls) was not significantly different ( P = 0.4). A large randomized prospective study comparing duplex surveillance and clinical follow-up is warranted. Copyright © 1996 The International Society for Cardiovascular Surgery.

New interventions in cerebrovascular disease: the role of thrombolytic therapy and balloon angioplasty.

The use of thrombolytic agents (plasminogen activators) in the early moments of ischemic stroke to achieve recanalization and potential neurologic improvement has been actively studied over the past 10 years. In the same period, endovascular techniques for cerebral revascularization have evolved significantly. Recent phase III studies, following angiography-based phase I and II studies of plasminogen activators in stroke, have described evidence of clinical benefit and contributors to morbidity (i.e., symptomatic hemorrhage) and mortality that limit the applicability of this approach. The limited formalized experience with percutaneous transluminal balloon angioplasty and stent placement in the carotid artery and cerebral circulation has given rise to concerns about the safety and appropriateness of the procedures in this territory. However, several prospective series support the feasibility of well-designed clinical trials.

In situ arterial allografting for aortoiliac graft infection: a 6-year experience

Between October 1988 and May 1994, all aortoiliac graft infections seen in the authors' service were treated by in situ arterial allografting after resection of any infected graft or tissue. Some 83 consecutive cases were treated; there were 68 isolated primary prosthetic infections (82%) and 15 aortoenteric fistulae (18%). Emergency arterial allografting was performed in five cases (6%), elective allografting in 64 cases (77%) and elective allografting after emergency palliative revascularization using a temporary prosthetic graft in 14 cases (17%). Arterial allografts were harvested from cadavers as part of a programme to retrieve multiorgan transplant tissue. Fifteen patients (18%) died either intra- or postoperatively. Three died during the operation, one from septic shock and two from uncontrollable coagulopathy. Twelve patients died in the early postoperative period, from from septic shock, two from myocardial infarction, two from pneumonia, one from a pulmonary embolism, one from an intestinal infarction, one from recurrence of a duodenal fistula and one from disruption of the native aorta at the suture line. Three patients presented with an early complication directly related to the use of the allograft. Eleven early survivors of the series died during follow-up. Among these late deaths, only one could likely be allograft-related. In four patients, the aortic segment of the allograft was mildly dilated on late computed tomography scan; three were reoperated on for disruption of the extra-abdominal segment of their allograft. All four cases were managed with simple suture of the allograft or with the use of a new allograft. Fifteen patients exhibited 19 late occlusive lesions of their allograft; 17 of these lesions had to be treated either with transluminal angioplasty or with surgery using autogenous or allograft material. In all but one case, secondary patency could be achieved through these additional procedures. Late occlusive disease was more prevalent in the femoral segment of the allograft than in the iliac or, moreover, the aortic segment. There were no late amputations in this series. Copyright © 1996 The International Society for Cardiovascular Surgery.