Use Of Percutaneous Transluminal Angioplasty Research Articles

An Integrative Review of Outcomes in Patients with Acute Primary Upper Extremity Deep Venous Thrombosis Following No Treatment or Treatment with Anticoagulation, Thrombolysis, or Surgical Algorithms

Primary upper extremity deep venous thrombosis (UEDVT) is a rare condition that typically affects young patients and can cause considerable long-term morbidity. Proposed treatments have included rest, heat, elevation of the affected limb, anticoagulation, thrombolysis, surgical decompression, percutaneous transluminal angioplasty (PTA), and stenting. However, the optimal management of primary UEDVT remains controversial. This study was an integrative review of the English-language literature since 1965 on primary UEDVT, with comparison of long-term symptoms, rethrombosis, and pulmonary embolism in 4 treatment algorithms: rest, heat, and elevation alone; anticoagulation alone; surgical decompression without thrombolysis; and algorithms including thrombolysis. Forty-one studies describing 559 patients met the criteria for inclusion. Statistically significant differences were found among the 4 treatment algorithms in the incidence of residual symptoms (p < 0.000), the incidence of pulmonary embolism (p < 0.000), and the incidence of rethrombosis (p < 0.027). Residual symptoms and the severity of residual symptoms were greatest in the rest, heat, and elevation algorithm (74%), followed by the surgical (60%), anticoagulation (44%), and thrombolysis (22%) algorithms. Pulmonary embolism was also greatest in the rest, heat, and elevation algorithm (12%), followed by the anticoagulation (7%), thrombolysis (1%), and surgical algorithms (0%), while rethrombosis was greatest in the thrombolytic algorithm (7%) followed by the surgical (3%), anticoagulation (2%), and rest, heat, and elevation (0%) algorithms. These results support the current clinical practice of a staged, multidisciplinary approach to treatment of primary UEDVT that includes thrombolytic therapy and possible surgical decompression. Further studies are needed to evaluate the natural history of patients treated with thrombolysis alone, to assess the optimal timing of surgical decompression, and to determine the best use of PTA and stenting in the multidisciplinary approach.

Vascular surgical society of great britain and ireland: percutaneous transluminal angioplasty for lower limb ischaemia

BACKGROUND: Percutaneous transluminal angioplasty (PTA) is increasingly performed for lower limb ischaemia of all severities, despite the absence of controlled data demonstrating its efficacy. The aim of this study was to examine the indications and outcome for lower limb ischaemia over a 16-year period. METHODS: A prospectively gathered database of 1287 consecutive PTAs performed between 1982 and 1997 was analysed. Two time intervals were compared: 1982-1991 and 1992-1997. RESULTS: Since 1992 there has been a fourfold increase in the number of PTAs performed. There has been a significant increase in the number of PTAs performed for critical ischaemia, occlusive lesions and at infrainguinal sites. Although there has been a significant reduction in morbidity, the number of immediate technical and clinical failures has increased (see Table ). CONCLUSION: Despite a lack of controlled data supporting a more liberal use of PTA in the treatment of lower limb ischaemia, there has been, in this regional vascular unit, a significant increase in the perceived clinical and anatomical indications for the procedure. Randomized controlled trials are urgently required to define the role of PTA in this condition.

Presidential address: Vascular surgery and the Midwestern Vascular Surgical Society in the new millennium

Presidential address: Vascular surgery and the Midwestern Vascular Surgical Society in the new millennium

The Usefulness of Percutaneous Transluminal Angioplasty of the Middle Cerebral Artery Stenosis in Patients with Transient Ischemic Attack

The Usefulness of Percutaneous Transluminal Angioplasty of the Middle Cerebral Artery Stenosis in Patients with Transient Ischemic Attack

The superficial femoral–popliteal vein transposition fistula: description of a new vascular access procedure

With advances in the medical care of patients with end-stage renal disease, an increasing number of patients continue to need reliable AV access after failure of multiple upper-extremity vascular access sites. In many cases, these failures are related to central venous outflow obstruction caused by previous subclavian vein catheters. Although it is technically possible to restore central venous patency in some patients with the use of percutaneous transluminal angioplasty and stent placement, 1-year patency rates as low as 17% have been reported with this approach. Given the success of using the superficial femoral–popliteal vein (SFPV) for arterial and venous reconstructions, I decided to use this conduit to construct a transposition AV fistula in the thigh of patients presenting for AV access surgery in the face of multiple failed upper-extremity access attempts and central venous occlusion. To my knowledge, this is the first study using this technique.

Extracranial vertebral artery stent placement: in-hospital and follow-up results.

The authors summarize their experience with stent deployment in the treatment of vertebrobasilar artery (VBA) insufficiency. This is an underdiagnosed condition, and the incidence of significant vertebral artery (VA) stenosis has been underappreciated. Medical therapy has been the mainstay of treatment because of the high rate of morbidity associated with surgical correction of VA stenosis. Recently, some authors have reported acceptable results with the use of percutaneous transluminal angioplasty, but this technique has significant weaknesses such as elastic recoil and problems in achieving safe treatment of dissections. The authors investigated the feasibility, safety, and outcome of VA stent placement in 50 patients in whom 55 vessels were treated using stents. Technical success was achieved in 54 (98%) of 55 vessels, with no procedure-related complications. However, one patient (2%) died of nonneurological causes, and one (2%) suffered a stroke that occurred within the 30-day postprocedural period and was related to a complicated coronary intervention. Clinical follow-up review performed at a mean of 25 +/- 10 months revealed two patients (4%) with recurrence of VBA symptoms. Six-month angiographic follow up was completed in 90% of eligible patients, with a 10% incidence of restenosis as defined by greater than 50% luminal narrowing. Vertebral artery stent placement is feasible in patients who have significant VA stenosis, with predictably good angiographically demonstrated and clinical results. The 6-month angiographically confirmed restenosis rate appears to be low, as does the clinical recurrence rate. This technique solves the problems of elastic recoil and the treatment of angioplasty-induced dissections. Further prospective comparison with medical preventive strategies is warranted.

Percutaneous transluminal angioplasty for intracranial vertebral and/or basilar artery stenosis

OBJECTIVE: Despite the growing clinical use of percutaneous transluminal angioplasty (PTA) for atherosclerotic lesions, application of this technique for intracranial vertebral and/or basilar arteries is not common. In this report, we present our experience with PTA for intracranial vertebrobasilar systems and assess its usefulness. PATIENTS AND METHODS: We report our experiences with PTA in six steno-occlusive lesions affecting intracranial vertebral and/or basilar arteries in five patients. One of the two patients with acute stroke had involvement of both the vertebral and basilar arteries, and the other had involvement of the dominant vertebral artery. In two of the other three patients, without acute stroke, the intracranial vertebral arteries were involved and in one the basilar artery was involved, but the symptoms were unresponsive to intensive medical therapy. PTA was performed for these lesions without complications and the clinical symptoms improved. During the procedure, we took care not to overdilate the lesions. RESULTS: These lesions were treated by PTA without complications and the clinical symptoms improved. CONCLUSION: The authors' experience suggests that PTA might be an effective therapy for stenoses of the intracranial vertebral and/or basilar arteries. In patients with acute stroke where there is not enough time for surgical treatment, emergency PTA is useful and improves the clinical symptoms. Further study is needed to confirm its long-term effectiveness for symptomatic stenosis of vertebrobasilar systems.

Intracranial internal carotid artery angioplasty: technique with clinical and radiographic results and follow-up.

Our objective is to describe the use of percutaneous transluminal angioplasty in eight patients with symptomatic high-grade atherosclerotic intracranial internal carotid artery stenoses. We describe our technique for performing the procedure and clinical and radiographic follow-up for an average of 53 months to determine the long-term results. Percutaneous transluminal angioplasty was shown to be an efficacious treatment for symptomatic intracranial internal carotid artery atherosclerotic disease in our group of patients.

Intermittent claudication in older patients. Practical treatment guidelines.

The prevalence of intermittent claudication (IC) increases with age; when questioned, older patients consider increased difficulty in walking to be a normal consequence of aging. Although the prognosis for the involved limb with IC is relatively good, IC is an important clinical predictor of increased cardiovascular mortality. It is important to effect a minimal strategy for determining the presence of lesions in different vascular regions: carotids, coronaries, aorta and renal arteries. The goals for the treatment of IC in the elderly are to improve the walking distance and quality of life and to increase survival. Practical guidelines for the treatment of IC are to first establish a correct diagnosis. Then, patients have to apply life-style modifications and participate in an exercise programme, with the next treatment step involving the use of antiplatelet drugs. However, it must be remembered that older patients could have limitations on exercise; in such cases, a vasoactive drug should be considered. The third guideline consists of multifocal evaluation of the arteries, specifically the coronaries, carotids and abdominal aorta. The existence of an iliac obstruction or stenosis requires consideration of the 2 last guidelines. In more than 75% of cases, elderly patients have femoropopliteal or distal arterial obstructions: exercise and a vasoactive drug should be employed in these instances. The presence of iliac lesions has to be discussed in the presence of a multidisciplinary team in a vascular centre, and should consider the usefulness of percutaneous transluminal angioplasty or surgery.

Does Angioplasty Improve the Quality of Life for Claudicants?: A Prospective Study

This study aims to analyze the impact of percutaneous transluminal angioplasty (PTA) for claudication on patients' quality of life (QOL). The patients in this study included 108 claudicants, 74 men and 34 women, with a median age of 67 years (range 40-87 years), who were assessed prior to and at 1, 3, and 6 months following PTA. This is the first report to demonstrate that the previously well-documented improvements in the clinical indicators of lower-limb ischemia are accompanied by improvements in individual QOL domains and in overall global QOL. These findings are detectable within a month following PTA and last at least 6 months. The results of this study may go some way to provide proof of efficacy for the procedure and thus help justify the recently questioned widespread use of PTA in clinical practice.

Chronic iliac artery occlusion: treatment with the Strecker stent after PTA

The purpose of this retrospective study was to evaluate the use of percutaneous transluminal angioplasty (PTA) and subsequent Strecker stent implantation for the treatment of chronic iliac artery occlusions. A total of 39 patients were subjected to this procedure. The occluded vessels were catheterized, dilated and subjected to stenting in all patients: the length of occlusion varied from 4.5 to 10.5 cm (mean 5.9), lesions were located in common iliac arteries (25), external iliac arteries (10) and in combinations of both (4). Twenty-five patients presented stage II according to Fontaine classification, nine patients stage III and five patients stage IV. The stent was mounted on balloon catheter and introduced through a 9 French sheet (for 8–10 mm stent diameter). After this procedure, 37 out of 39 patients showed a statistically significant increase in the Doppler sonographic ankle-arm index (AAI) ( P=0.001) and improvement of clinical symptoms, while in two patients a complete occlusion resulted due to long dissection not covered by the stent in one case and to stent misplacement in the other case. After stenting, 27 patients improved to stage I, ten patients to stage IIa and two patients showed no changes. Two complications were observed: one groin hematoma and one distal embolization. At a 6-month follow-up, a 89.7% of patency was observed. This study shows that Strecker stent can be successfully employed in addition to PTA to treat occlusions of the iliac arteries.

Ischemic Cerebrovascular Disease (Stroke)

Treatment of symptomatic intracranial atherosclerotic stenosis usually involves maximizing medical therapy. In patients with medically refractory symptoms despite maximum pharmacologic therapy, intracranial angioplasty and/or stenting has become an accepted treatment option. The use of percutaneous transluminal angioplasty (PTA) for idiopathic intracranial stenoses has not been reported to date. We describe a case of idiopathic intracranial stenosis which was refractory to medical therapy and was successfully treated with percutaneous transluminal angioplasty. The presenting symptoms included multiple episodes of aphasia and right-sided weakness as well as a left basal ganglia infarct. The patient underwent treatment with two intracranial angioplasty procedures. There was a recurrence of the stenosis and symptoms following the first procedure. However, after a second treatment with a slightly larger balloon, flow in the MCA normalized. Furthermore, the symptoms attributed to her MCA stenosis had essentially resolved. This case suggests that patients with medically refractory idiopathic intracranial stenosis can be successfully treated with percutaneous transluminal angioplasty.

Occlusion of the superior mesenteric artery in a patient with Polycythemia vera: Resolution with percutaneous transluminal angioplasty

The case is reported of a 46-year-old male patient with polycythemia vera (PV) treated with phlebotomy who developed an occlusive thrombosis of the superior mesenteric artery 2 years after the diagnosis. He was successfully managed with percutaneous transluminal angioplasty. The patient did not develop any other thrombotic phenomena. To our knowledge, there are no previous reports on the use of percutaneous transluminal angioplasty in the management of arterial thrombotic complications in PV patients.

Budd-Chiari syndrome caused by obstruction of the hepatic inferior vena cava: immediate and 2-year treatment results of transluminal angioplasty and metallic stent placement.

To assess the usefulness of percutaneous transluminal angioplasty (PTA) and expandable metallic stent (EMS) placement for treatment of Budd-Chiari syndrome (BCS). Thirty-two patients with BCS were treated by PTA alone or by PTA and EMS placement. Among the 32 patients, a membranous obstruction was found in 24 and a segmental stenosis or occlusion in 8 patients. The follow-up period for PTA was 38-68 months (mean 52.2 months); for EMS it was 20-36 months (mean 24.3 months). Twenty-one patients underwent PTA as the primary treatment. Of these, one patient died of disseminated intravascular coagulation shortly after the procedure; 20 had good to excellent initial angiographic and clinical results. Of the 20, restenosis or reocclusion developed in 10 patients (48%), all before 27 months; 8 patients (38%) became symptomatic, and 2 remained symptom-free for a total recurrent obstruction rate of 50%. The EMS group of 17 patients included 11 patients who underwent primary stenting and 6 patients with secondary stenting after recurrence following primary PTA; restenosis was demonstrated in only 2 patients (12%). We conclude that PTA alone produces excellent short-term results and about 50% sustained patency after 2 years in patients with BCS; therefore it should remain the procedure of first choice. Stents should be reserved for primary or secondary PTA failures.

Effect of the increasing use of coronary angioplasty on outcome at one year in patients with unstable angina.

To determine whether the increasing use of percutaneous transluminal angioplasty in patients with unstable angina has reduced the need for bypass surgery and whether this change in the choice of treatment affected the outcome at one year in patients with unstable angina who were admitted to hospital in two different periods of time. Retrospective analysis of consecutive patients with unstable angina (angina at rest with ST-T changes during pain) who underwent coronary arteriography in two different periods of time. 158 patients were admitted to hospital between January 1988 and June 1989 (group 1) and 140 patients admitted between January 1992 and June 1993 (group 2). Coronary angioplasty procedures nearly doubled from 29% in group 1 to 56% in group 2 whereas bypass surgery decreased from 36% in group 1 to 23% in group 2 (P < 0.01). Coronary angioplasty increased and bypass surgery decreased in patients with one vessel disease (P < 0.01), two vessel disease (P < 0.05), and three vessel disease (P < 0.01). Coronary angioplasty also increased and bypass surgery decreased in refractory angina and in patients with ejection fraction < 0.50 (both P < 0.05). At 1-year follow up, 14 patients in group 1 (9%) and 10 in group 2 (7%) either died or had myocardial infarction (P = NS). Revascularisation procedures were needed in 16 group 1 patients (10%) and 27 group 2 patients (19%, P < 0.05). Coronary angioplasty became more widely used in patients with unstable angina. This reduced the need for bypass surgery in patients with multivessel disease, refractory angina, and depressed left ventricular function. This change in treatment did not affect 1-year mortality or the myocardial infarction rate. More patients in the more recent group in which angioplasty was the preferred treatment required a further revascularisation procedure than in the earlier group in which bypass grafting was more often used as the initial treatment.

Femoropopliteal angioplasty in patients with claudication: primary and secondary patency in 140 limbs with 1-3-year follow-up.

To determine the usefulness of percutaneous transluminal angioplasty in the femoropopliteal arteries in patients with claudication. In a prospective study of 106 claudicants (71 men and 35 women, aged 41-90 years [mean, 67 years]), a total of 208 lesions in 140 limbs were treated. The patients were followed up for 12-36 months. The patency rates were based on determination of the ankle-brachial index. The hemodynamic success rate for all the treated limbs was 89%, 99% for femoropopliteal stenoses (n = 71) and 80% for femoropopliteal occlusions (n = 69). In multiple logistic regression analysis, a smaller number of diseased vessels (one to two vs three to seven) and milder lesion severity (stenosis vs occlusion) correlated favorably with early success. Survival analysis with the Kaplan-Meier method according to established criteria revealed 1-, 2-, and 3-year primary patency rates of 47% (27 of 57 limbs), 41% (14 of 34 limbs), and 43% (three of seven limbs), respectively. In selected cases, good primary success and acceptable long-term results can be achieved with femoropopliteal angioplasty in claudicants.

Resolution of petrous internal carotid artery stenosis after transluminal angioplasty

Percutaneous transluminal angioplasty is commonly used for treatment of peripheral vascular disease, but only recently has it been applied to craniocervical lesions. The successful use of percutaneous transluminal angioplasty for treatment of an isolated high-grade stenosis of the petrous internal carotid artery is described in a patient with progressive ischemic symptoms despite maximum medical management. At his 2-year follow-up examination, the patient remained asymptomatic with angiographic evidence of progressive resolution of the stenotic lesion and indirect evidence of improved hemispheric blood flow ipsilateral to the lesion. Percutaneous transluminal angioplasty may provide an effective means of treatment for selective intracranial artherosclerotic stenosis.

A confidence profile analysis of the results of femoropopliteal percutaneous transluminal angioplasty in the treatment of lower-extremity ischemia

The many reports on the use of percutaneous transluminal angioplasty (PTA) for treating lower-extremity ischemia were analyzed to determine the outcomes of femoropopliteal PTA used in patients with intermittent claudication (IC) and with more severe limb-threatening ischemia ("salvage"). The Confidence Profile Method was used to interpret and adjust the evidence from 12 selected clinical reports, and to combine the data into single best estimates of the outcomes that were considered important for decision making. The following combined estimates were obtained: The early success rate was 89% +/- 2.5% after PTA for IC, compared with 77% +/- 4% after PTA for salvage. The largest decline in patency occurred during the first 6 to 12 months. After 2 years there was little further attrition. Three-year patency was 62% +/- 9% for IC and 43% +/- 7% for salvage. The risk of procedure-related mortality and limb loss was low, estimated at 0.5% and 1%, respectively. The risk of serious complications requiring surgical repair was about 2.5%. The Confidence Profile Method is a novel way of obtaining this information from the imperfect clinical literature. The method incorporates subjective judgments and assumptions and gives quantitative and visual representations of both the magnitude of the estimated outcome and the uncertainty associated with it. The results are as strong as the assumptions incorporated in them are valid. The estimates derived in this study can be used for any decision on the use of PTA in the femoropopliteal segment.

A confidence profile analysis of the results of femoropopliteal percutaneous transluminal angioplasty in the treatment of lower-extremity ischemia

The many reports on the use of percutaneous transluminal angioplasty (PTA) for treating lower-extremity ischemia were analyzed to determine the outcomes of femoropopliteal PTA used in patients with intermittent claudication (IC) and with more severe limb-threatening ischemia (“salvage”). The Confidence Profile Method was used to interpret and adjust the evidence from 12 selected clinical reports, and to combine the data into single best estimates of the outcomes that were considered important for decision making. The following combined estimates were obtained: The early success rate was 89% ± 2.5% after PTA for IC, compared with 77% ± 4% after PTA for salvage. The largest decline in patency occurred during the first 6 to 12 months. After 2 years there was little further attrition. Three-year patency was 62% ± 9% for IC and 43% ± 7% for salvage. The risk of procedure-related mortality and limb loss was low, estimated at 0.5% and 1%, respectively. The risk of serious complications requiring surgical repair was about 2.5%. The Confidence Profile Method is a novel way of obtaining this information from the imperfect clinical literature. The method incorporates subjective judgments and assumptions and gives quantitative and visual representations of both the magnitude of the estimated outcome and the uncertainty associated with it. The results are as strong as the assumptions incorporated in them are valid. The estimates derived in this study can be used for any decision on the use of PTA in the femoropopliteal segment.

Failed percutaneous transluminal renal angioplasty: Experience with lesions requiring operative intervention

Percutaneous transluminal angioplasty (PTA) has received widespread publicity as a safe, simple, and successful alternative to operation for the management of renal artery stenoses and renovascular hypertension (RVH). Although, in our institution, the primary management of RVH remains operative revascularization, with more than 750 such procedures having been done, we have had the opportunity to manage a spectrum of PTA failures in nine patients during the last 5 years. These include (1) acute dissection of atherosclerotic lesions and occlusion of the distal renal artery requiring emergency operation; (2) unilateral perforation and bilateral thrombosis of fibrodysplastic branch renal artery lesions requiring staged ex vivo reconstruction; (3) cholesterol embolization and recurrence to total occlusion of orificial atherosclerotic lesions with loss of excretory renal function; (4) chronic dissection from repeated ”temporarily successful“ PTAs of medial fibrodysplastic lesions; and (5) rapid recurrence and acceleration of hypertension in a 17-year-old girl with congenital renal artery stenoses. In each instance operation was complicated by an intense perivascular inflammatory response from the previous PTA and required a more complex reconstruction than would have been needed originally. These sequelae argue for moderating enthusiasm for the use of PTA and for limiting its routine use to nonorificial atherosclerotic lesions and fibrodysplastic lesions restricted to the main renal artery. Orificial atherosclerotic lesions, branch fibrodysplastic lesions, and congenital stenoses have a high probability of failure, complications, or both when treated by PTA and should be considered for primary operative intervention.