Percutaneous transluminal angioplasty with the Grüntzig balloon catheter. A review of 70 cases

Percutaneous revascularization for ischemic nephropathy: the past, present, and future

Occlusion of the renal arteries can threaten the viability of the kidney when severe, in addition to accelerating hypertension and circulatory congestion. Renal artery stenting procedures have evolved from a treatment mainly for renovascular hypertension to a maneuver capable of recovering threatened renal function in patients with “ischemic nephropathy” and improving management of congestive heart failure. Improved catheter design and techniques have reduced, but not eliminated hazards associated with renovascular stenting. Expanded use of endovascular stent grafts to treat abdominal aortic aneurysms has introduced a new indication for renal artery stenting to protect the renal circulation when grafts cross the origins of the renal arteries. Although controversial, prospective randomized trials to evaluate the added benefit of revascularization to current medical therapy for atherosclerotic renal artery stenosis until now have failed to identify major benefits regarding either renal function or blood pressure control. These studies have been limited by selection bias and have been harshly criticized. While studies of tissue oxygenation using blood oxygen level dependent (BOLD) MR establish that kidneys can adapt to reduced blood flow to some degree, more severe occlusive disease leads to cortical hypoxia associated with microvascular rarefication, inflammatory injury and fibrosis. Current research is directed toward identifying pathways of irreversible kidney injury due to vascular occlusion and to increase the potential for renal repair after restoring renal artery patency. The role of nephrologists likely will focus upon recognizing the limits of renal adaptation to vascular disease and identifying kidneys truly at risk for ischemic injury at a time point when renal revascularization can still be of benefit to recovering kidney function.

Percutaneous transluminal angioplasty in adults less than 45 years of age with premature lower extremity atherosclerosis

Despite poor results reported with conventional vascular bypasses in young adults with ischemia from premature lower extremity atherosclerosis (PLEA), little attention has been given to alternative revascularization techniques. This study evaluated 32 patients (21 males and 11 females) < 45 years of age with PLEA who underwent 53 primary percutaneous transluminal angioplasty (PTA) procedures for treatment of 46 ischemic limbs. A residual arterial stenosis < 30% was achieved in 83% of PTA sites. Mean degree of stenosis decreased from 79.9% to 24.1% (p < 0.0001). Clinical improvement in ischemic symptoms was obtained in 39 (85%) limbs. Hemodynamic improvement was achieved in 31 (70%) of 40 limbs as documented by ankle/brachial indices. All criteria for early clinical success were met in 70%. Another 13% met all criteria except that the residual stenosis was < 50%. Hematoma and early restenosis were reported in two patients each. Mean follow-up was 27.3 months (range 1 to 84 months). Cumulative patency by life-table analysis was 81% at 1 year, 77% at 2 years, and 71% at 3 years. Thirteen (41%) patients required secondary PTA or bypass; 85% were performed within 1 year. Two patients had adjunctive bypasses; six (19%) were performed after PTA failure. Only one (3%) patient required major amputation. Neither cardiovascular risk factors, treatment indication, location of the diseased arterial segment, nor quality of distal runoff vessels predicted the need for secondary PTA or surgical procedures. PTA of the proximal arteries in young patients with PLEA is an effective primary revascularization technique with results comparable to those of conventional operative revascularization procedures.

Stenting of a renal artery stenosis achieves better relief of the obstructive lesion than balloon angioplasty

A balloon-expandable (Palmaz-Schatz) stainless steel stent was utilized following balloon angioplasty (PTRA) to determine if the obstructive lesion, using quantitative methods (automated measuring the diameter stenosis, and transstenotic peak systolic and mean pressure gradients), was significantly further reduced or abolished. Hemodynamic transstenotic gradient and stenoses measurements were made during 21 renal artery stenting procedures; prior and following PTRA, and subsequent to stent deployment. The stent sizes placed in the renal arteries were 5 mm (19%), 6 mm (67%), and 7 mm (14%). The results were as follows: [table: see text] The balloon-expandable (Palmaz-Schatz) stent significantly further reduced, and in fact effectively abolished, the obstructive renal artery lesion in comparison to balloon angioplasty (PTRA). The stent's effectiveness with regard lesion recurrence, maintenance, and preservation of renal function; cure or improved management of hypertension; and survival will be determined by careful clinic follow-up.

Adjunctive intraoperative linear extrusion (Fogarty-Chin) balloon angioplasty

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Chronic lower limb ischaemia. A prospective randomised controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA)

In a prospective randomised study, performed over a 6-year period, 102 patients with severe lower limb ischaemia or claudication resistant to exercise training were randomised either to percutaneous transluminal angioplasty (PTA) or vascular surgery. Only patients who could be treated by both methods were included, constituting only 5% of the total number of patients treated during this period. The two groups were similar regarding age, severity of symptoms and diabetes. The immediate and 1-year results showed similar success and complication rates. There was, however, a significantly shorter hospital stay for patients treated with PTA. Due to early complications and initial failures PTA should, however, only be used in institutions where vascular surgical facilities are available since PTA demands access to such treatment.

Long-term results after percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis--the importance of intensive follow-up

The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure gradient and renal venous renin measurement. Patients were scheduled for regular follow-up after the PTRA and a deterioration in blood pressure or renal function was an indication for re-evaluation, and reintervention if necessary. Sixty-five patients had 71 renal artery stenoses where PTRA was attempted. It was technically successful in 59 stenoses and two occlusions and failed in ten (14%). At the end of follow-up (median 56 months [2-99]), the primary patency rate was 55%, 27 had restenosed and four were occluded, all but two within 12 months. Seventeen were treated by a further PTRA and eight by surgical reconstruction. At the end of follow-up the secondary patency after all interventions was 90%. One patient died 1 month after PTRA, and at the end of follow-up 21 patients (32%) had died, most of them (80%) from cardiovascular disease. Multivariate analyses showed a significantly reduced survival rate in patients with multiocular atherosclerosis, renal insufficiency, contralateral renal artery stenosis and ischaemic heart disease. At the end of follow-up 90% of the patients were cured or improved with regard to blood pressure. In patients with impending renal insufficiency renal function was improved in 50% and unchanged in 39%. With this strategy 55% of the patients needed only one treatment with PTRA, 25% needed a re-PTRA and 20% had to be operated on. PTRA can be recommended as initial treatment of atherosclerotic renal artery stenosis provided intensive follow-up and aggressive reintervention are performed when indicated.

Clinical outcome and health care costs in renal revascularization--percutaneous transluminal renal angioplasty versus reconstructive surgery

Clinical outcome and health care costs related to investigation, treatment with either percutaneous transluminal renal angioplasty (PTRA) or reconstructive surgery, and follow-up of patients with renovascular hypertension with or without uraemia were analysed in 21 PTRA-treated and 16 operated patients. Most renal artery stenoses were atherosclerotic. Nineteen PTRAs were successful or partly successful and two failed; the patients were operated on without delay. All surgical reconstructions were successful. In the PTRA group six restenoses occurred after 4-24 months. Four were treated with re-PTRA and two were operated on. No recurrence occurred in the operated group. At the end of follow-up (median 48, range 9-84 months) primary patency in the PTRA group was 69 per cent and in the operated group 100 per cent. Secondary patency in the PTRA group was 100 per cent. With regard to hypertension, including primary and secondary results, 19 out of 21 (90 per cent) patients were improved in the PTRA group and 13 out of 16 (81 per cent) in the operated group. The diagnostic and preprocedure costs were the same in both groups, whereas the procedure and postprocedure costs were lower in the PTRA group. However, the follow-up costs were considerably higher because of recurrences and their treatment in the PTRA group. The total median cost of reconstructive surgery was 12 per cent higher than for PTRA, a non-significant difference.

Long-term results of aortoiliac reconstruction

To facilitate evaluation of new and evolving interventional strategies in the management of aortoiliac occlusive disease, the collective long-term experience with traditional operative reconstruction was reviewed. Endarterectomy, currently the procedure of choice for a limited number of patients with disease localized to the aorta and common iliac arteries, has demonstrated 10-year primary patency rates of 48%-77%. By comparison, prosthetic in situ replacement or bypass grafting, commonly performed for more extensive lesions and in the presence of aneurysmal degeneration or total occlusion of the aorta, has yielded 10-year primary patency rates of 62%-79%. Cumulative graft patency can often be extended by means of thrombectomy, thrombolysis, and repair of thrombosed graft limbs, with 20-year extended cumulative patency rates of 49%-68%. The long-term success of operative reconstruction is highly dependent on the extent of coexistent peripheral occlusive disease, with progression of outflow disease representing the single most important factor associated with thrombosis of endarterectomy sites or prosthetic bypass grafts. Further improvements in long-term outcome for all modes of intervention in aortoiliac occlusive disease require increased attention to the minimization of risk factors associated with the underlying atherosclerotic disease process.

Balloon angioplasty combined with vascular surgery

Seventy-nine intra-operative balloon angioplasties were performed in 72 patients undergoing a vascular reconstructive procedure over a 7-year-period (1981 through December 1987). The primary purpose of balloon angioplasty was either to increase inflow (26 procedures) or outflow (53 procedures) in association with a planned vascular operation and to avoid more extensive operative procedures in high risk patients. Peroperative balloon angioplasty involved atherosclerotic stenotic lesions in 26 iliac, 37 femoro-popliteal and 10 crural arteries. In 6 cases distal graft anastomotic stenoses were dilated. Follow-up ranged from 2 to 78 months (mean 32.4 months). The overall initial success rate was 84.8% and five procedure related complications were seen. One iliac restenosis with distal thrombosis, two superficial femoral artery dissections, one tibial artery thrombosis necessitating below knee amputation and one distal popliteal embolus after superficial femoral artery dilatation. There were no postoperative deaths. Fifty-one patients remained asymptomatic during follow-up. One iliac, eight femoro-popliteal and two tibial arteries restenosed with or without occlusion and thrombosis. The 3-year cumulative patency rate for the iliac and femoro-popliteal angioplasties is 80.2%. Intra-operative balloon angioplasty broadens the surgical therapeutic armamentarium available to correct multiple symptomatic arterial lesions. In addition this technique offers several advantages over a two stage procedure.

Renal vascular disease: pathology of large blood vessel disease

Lesions of the extrarenal arteries which are associated with hypertension are described. Included are descriptions of the development, stages, and complications of atherosclerotic plaques; intimal fibroplasia and the medial fibromuscular dysplasias; Takayasu's aortitis; radiation injury; and a newly described arterial disease, medial agenesis. Also described is the development of atherosclerosis in saphenous vein bypass grafts and the effects of transluminal angioplasty.

Percutaneous transluminal angioplasty of the arteries of the lower limbs: a 5 year follow-up

A total of 482 percutaneous transluminal angioplasties (PTAs) of the arteries of the lower limbs were performed in 411 patients between 1977 and 1983. The 5 year patency rate, calculated by the life table method, was 83% for iliac and 58% for femoropopliteal PTA. Clinical improvement after the procedure was confirmed by a significant drop of the arm-ankle pressure difference: 48 +/- 5 mm Hg before vs 17 +/- 5 mm Hg 2 years after iliac PTA (p less than .01) and 73 +/- 5 mm Hg before vs 28 +/- 6 mm Hg after femoropopliteal PTA (p less than .01). The majority of reocclusions occurred within the first year after angioplasty. Patients with stenoses or occlusions of less than 3 cm had a favorable long-term patency rate of 74%. Conversely, patients with femoropopliteal occlusions presenting with pain at rest, diabetes, occlusions of greater than 3 cm, or poor distal runoff had an elevated rate of reocclusion. Complications, which occurred in 8% of the patients in whom PTA was attempted, included local hemorrhage, dissection, embolism, and spasm necessitating surgical intervention in 2%. No deaths or amputations were a direct consequence of PTA. PTA of arteries of the lower limbs may thus be regarded as a valid complementary treatment to vascular surgery in patients with occlusive disease of the peripheral arteries.

Percutaneous transluminal angioplasty. The radiologist's contribution to the treatment of vascular disease

Percutaneous transluminal angioplasty is a nonsurgical treatment for vascular disease. It is relatively safe and economical and may be an alternative, or an adjunct, to surgery, or may be helpful where no surgical alternative exists. Percutaneous transluminal angioplasty is applicable to nearly every system, except the carotid bifurcation plaque.

The cost of underutilization. Percutaneous transluminal angioplasty for peripheral vascular disease

Despite the considerable literature on the overuse of new medical technologies, little attention has been paid to the biologic and monetary costs that may be incurred by underuse. Percutaneous transluminal angioplasty as a treatment for peripheral vascular disease is an example of an important technology that has been underused. Although angioplasty alone is less costly but also less efficacious than surgery, a strategy that combines the two procedures (angioplasty first, then surgery if angioplasty is unsuccessful or if occlusion recurs) is uniformly superior to surgery alone in patients who have lesions for which angioplasty can be considered. From a nationwide perspective, if 40 per cent of all patients with iliac or femoral disease (or both) requiring intervention were treated with the combined strategy, there would be an estimated savings (as compared with surgery alone) of 352 lives and $82 million, as well as an additional 5006 patent limbs. Despite these advantages, the use of angioplasty during the period under consideration (up to 1980) was limited, possibly because of the mechanism of patient triage and the inertial forces that operate when a therapeutic method that appears effective--even if more complex and hazardous than a newer approach--has been widely applied.

Treatment of advanced vascular disease with intra-arterial thrombolytic therapy followed by arterial dilatation

A patient with severe arterial insufficiency was successfully treated with a combination of intra-arterial low-dose streptokinase and percutaneous transluminal dilatation. The judicious use of a combination of these two techniques may extend the application of each technique and allow salvage of some severely ischemic extremities.

Current status of percutaneous transluminal angioplasty

With the development of a dilating balloon catheter that permits percutaneous treatment of many arterial stenoses and some occlusions, a definite advance in the therapy of peripheral vascular disease has been made. It is still too early to be certain what ultimate position this means of therapy will take in the overall treatment of vascular disease, as its use is still being extended and long-term results are not yet clearly known. When compared with surgical therapy, however, it has some striking advantages, although the durability of its effect appears to be less. Despite the fact that more time and experience are needed before its ultimate position is established, we believe that the evidence to date warrants inclusion of this form of therapy in the armamentarium of every major vascular center.

Successful treatment of renovascular hypertension with a percutaneous transluminal angioplasty

We report a case of typical renovascular hypertension due to right renal artery stenosis treated with percutaneous transluminal angioplasty. The followup arteriogram demonstrated merely a partial dilatation of the stenotic segment but hypertension was remarkably improved. A right-to-left ratio of plasma renin activity in the renal venous effluent decreased from 2.67:1 to 1.10:1 following treatment. Affected renal function in the previously stenotic side was ameliorated. The procedure was well tolerated by the patient and blood pressure remained normotensive during the 5 months after angioplasty.

Percutaneous transluminal angioplasty of renal artery stenosis

Percutaneous transluminal angioplasty was performed in 7 patients with hypertension and renal artery stenosis, caused by atherosclerosis in 3 patients and fibromuscular disease in 4. The balloon dilatation was successful in all patients. In 6 patients the blood pressure was normalized within 5 days after the procedure, and remained so in 5 on follow up 3 to 10 months later.

Complications after percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty is being widely advocated as an alternative to direct arterial reconstructive surgery. Distressing complications of percutaneous transluminal angioplasty have been noted, including anterograde dissection of the femoral and iliac arteries with acute thrombosis and widespread embolization of the mesenteric and peripheral circulation leading to death, thrombosis and embolization of the renal arteries with infarction of the kidney and thrombosis of the popliteal trifurcation. While percutaneous transluminal angioplasty promises to be a useful adjunct to our vascular armamentarium in properly selected poor risk patients, we do not believe that it is safer than reconstructive surgery. The most suitable lesions for dilatation appear to be flat, solitary atheromas and segmental scars, which comprise only a small percentage of the total spectrum of the atherosclerosis. An alternative approach to percutaneous transluminal angioplasty entails the combined efforts of the angiographer and surgeon utilizing fluoroscopic guidance and surgical exposure of the affected vessel in the operating room. We hope that employment of the latter technique will result in more selective application of transluminal angioplasty with fewer complications and better long-term results.

Fibromuscular disease of carotid arteries: long term results of graduated internal dilatation

From 1967 to 1979, 25 patients (pts) were operated on for fibromuscular disease (FMD) of the internal carotid artery (ICA). Eleven patients (44%) had transient weakness of an extremity, 4 had amaurosis fugax and 6 (24%) had an asymptomatic carotid bruit. Bilateral carotid arteriography showed significant stenotic lesions in 23 pts (92%) (bilateral in 10), arterial dissection in 1, and severe associated atherosclerosis with ICA endarterectomy and graduated internal dilatation (GID) (9 bilateral); 2 underwent GID with ICA endarterectomy and patch graft: 1 pt had tube graft replacement of the ICA. There was no operative mortality. One pt had a stroke during operation after tube graft replacement of the ICA. Of the 19 pts followed for 2 to 12 years (mean 7.3 years), 2 had late recurrence of mild symptoms. One pt required GID of the contralateral ICA recurrence of symptoms 4 years postoperatively. Graduated internal dilatation of fibromuscular disease of the internal carotid artery can produce long term relief of symptoms; recurrence is rare.

Non-surgical management of peripheral vascular disease: a review

Although the outlook for a pronounced improvement in the ischaemic limb that cannot be surgically treated remains bleak, cessation of smoking, encouragement of exercise, and the withdrawal of vasoconstricting agents may give some symptomatic relief. There is little evidence that vasodilators or antiplatelet agents have much to offer.

Percutaneous transluminal angioplasty of the iliac artery

Stenosis in the right common iliac artery of a 61-year-old man was manifested as pain in the right leg and foot and cyanosis of the second and third toes. Dilatation of the lesion was performed using a Grüntzig catheter; arteriography and measurement of femoral artery pressure confirmed a successful result. The patient was pain free at six-month follow-up. Dilatation of stenoses by percutaneous transluminal angioplasty provides an alternative to conventional operative procedures, with lower cost and morbidity plus an acceptable success rate.