Complications of transluminal angioplasty

Anemia to Median Nerve Palsy

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

Assessment of Efficacy and Complications of Endovascular Interventions for Critical Limb Ischemia in Germany: A Nationwide Study

PURPOSE

 Endovascular interventional radiological procedures have become the mainstay for the treatment of critical limb ischemia (CLI) due to arterial stenosis or occlusion. Open surgical or endovascular procedures, such as percutaneous transluminal angioplasty (PTA) or stenting can be used as a treatment strategy. The aim is to evaluate the success and major complication rates of interventional radiology treatments for CLI in Germany in 2021, and to compare these results with internationally published data.

MATERIALS AND METHODS

 Data for PTA and stenting in CLI for 2021 was obtained from the quality management system of the German Society of Interventional Radiology (DeGIR). 16 393 PTA procedures, 701 stenting procedures, and 8110 combined procedures were documented for 2021. Data was analyzed for technical and clinical success rates, as well as major complication rates documented mainly as major bleeding, distal embolization, and aneurysm formation.

RESULTS

 PTA had technical and clinical success rates of 96.3 % and 92.33 %, respectively. Stenting had technical and clinical success rates of 98.7 % and 96.15 %, respectively. PTA and stenting combined had success rates of 98.71 % and 96.91 %, respectively. The major complications were mainly: major bleeding (PTA: 0.40 %; stenting: 1.28 %; PTA and stenting: 0.54 %), distal embolization (PTA: 0.48 %; stenting: 1 %; PTA and stenting: 0.96 %), and aneurysm formation (PTA: 0.19 %; stenting: 0.43 %; PTA and stenting: 0.19 %). All procedures showed high technical and clinical success rates, while the complication rates were low.

CONCLUSION

 Interventional radiologists in Germany perform effective and safe treatment for CLI, achieving outcomes that tend to surpass internationally published data.

KEY POINTS

  · German interventional radiologists provide safe and effective critical limb ischemia treatment.. · Major complications occurred at maximum in 1.28 % of cases.. · Outcomes tend to surpass international data, indicating strong performance..

Popliteal artery pseudoaneurysm and secondary ipsilateral deep vein thrombosis caused by an exostosis in a mature adult

Exostosis (also known as osteochondroma) is the most common benign bony lump of young people, usually arising at the distal femur. Vascular complications associated with exostoses are rare and include true aneurysm or pseudoaneurysm formation, deep vein thrombosis, arteriovenous fistula, and arterial insufficiency of the limbs. Few case reports describe pseudoaneurysms resulting from exostoses in mature adults, and no consensus has been reached regarding the optimal therapy. We report the case of a 51-year-old male patient complaining of persistent right thigh pain with a pulsatile mass and right calf swelling, without a history of trauma or hereditary multiple exostoses. The diagnosis was confirmed by computed tomography angiography, which showed a pseudoaneurysm of the popliteal artery resulting from an exostosis on the lateral aspect of the distal femur. A Doppler ultrasound examination confirmed popliteal vein thrombosis caused by the compression of the pseudoaneurysm. Surgical treatment consisted of removing the exostosis, excision of the pseudoaneurysm, and an end-to-end anastomosis. The deep vein thrombosis was treated with rivaroxaban for 3 months. The patient was discharged after 6 days and followed up for 6 months with satisfactory results.

Factors related to high bifurcation level of common femoral artery

BACKGROUND

Common femoral artery (CFA) puncture is performed for endovascular treatment. However, we sometimes experience branch punctures when the CFA bifurcation level is high. In this study, we examined the frequency of high CFA bifurcation level and related factors.

METHODS

The CFA bifurcation level was identified in 100 patients, who underwent cerebral angiography or endovascular treatment by femoral artery (FA) puncture, on 191 sides. The height of the CFA bifurcation level was classified into three groups: normal, high, and very high. Age, gender, left-right difference, height, weight, body mass index, and comorbidities, including hypertension, dyslipidemia, and diabetes, were examined to determine the factors associated with high CFA bifurcation level.

RESULTS

The normal, high, and very high groups were on 142, 35, and 14 sides, respectively. The high and very high groups, which were defined as high CFA bifurcation levels, accounted for 25% of all patients. Multivariate analysis revealed that the proportion of patients with high CFA bifurcation levels was higher in the elderly (p = 0.009) and those with a history of diabetes (p = 0.042).

CONCLUSIONS

Approximately one-fourth of all patients undergoing cerebral angiography or endovascular treatment by FA puncture had high CFA bifurcation levels, which had a significant association with old age and history of diabetes. For urgent treatment, FA puncture might be performed at a higher level below the inguinal ligament if patients are elderly of those with a history of diabetes.

Management of Acute Complications during Endovascular Procedures in Peripheral Arterial Disease: A Review

Endovascular therapy, as opposed to surgical bypass, has become the mainstay for peripheral arterial disease even in long segment occlusions. Complications can occur during the arterial access, catheter manipulation, balloon dilation, and/or stent placement. Given the high prevalence of comorbidities such as diabetes, hypertension, renal dysfunction, and coronary artery disease in these patients, early identification of procedural complications and initiation of treatment are of paramount importance. This review aims to provide comprehensive data on the identification and management of commonly encountered endovascular complications during endovascular interventions in peripheral arterial disease.

Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes

PURPOSE

 We aimed to analyze the technical success rate of manual percutaneous aspiration thrombectomy (PAT) in patients with peripheral arterial thromboembolism as a complication of infrainguinal percutaneous transluminal angioplasty (PTA) and we sought to evaluate the 30-day postintervention clinical outcome.

MATERIALS AND METHODS

 We retrospectively identified 29 patients (men/women, 18/11; mean age, 74 years) who underwent infrainguinal PAT to treat thromboembolic complications of infrainguinal PTA. Primary and secondary technical successes were defined as residual stenosis of < 50 % of the vessel diameter after PAT alone and PAT with additional PTA, respectively. Clinical outcome parameters (e. g., amputation, need for further intervention) were evaluated during the first 30 days after intervention.

RESULTS

 The primary and secondary technical success rates were 58.6 % (17/29) and 79.3 % (23/29), respectively. Clinical outcome data were available for 93.1 % (27/29) of patients. No further intervention was required within 30 days in 81.5 % (22/27) of patients. Four patients underwent minor amputations owing to preexisting ulcerations (Rutherford Category 5), and no patients underwent major amputations (Rutherford Category 6). Revascularization of the previously treated vessel segment with PTA was necessary on the first postintervention day in one patient.

CONCLUSION

 Manual PAT, with PTA if needed, has a good technical success rate and satisfactory early clinical outcome in patients with iatrogenic thromboembolic complications after infrainguinal PTA.

KEY POINTS

  · Manual PAT is a possible first-choice treatment of infrainguinal PTA-induced acute thromboembolism.. · Performing additional PTA increases the success rate of manual PAT.. · Unlike catheter-directed intraarterial lysis, manual PAT carries no risk of bleeding..

CITATION FORMAT

· Schicho A, Bäumler W, Verloh N et al. Percutaneous Aspiration Thrombectomy for Arterial Thromboembolic Occlusion Following Percutaneous Transluminal Angioplasty: Technical Success Rates and Clinical Outcomes. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1652-1726.

Pipeline Flex embolisation device with Shield Technology for the treatment of patients with intracranial aneurysms: periprocedural and 6 month outcomes

BACKGROUND AND PURPOSE

The Pipeline Flex embolisation device with Shield Technology (Pipeline Shield) is a novel flow diverter which reduces intra-vessel thrombogenicity. This study summarises periprocedural outcomes and 6-month follow-up results following its introduction in a tertiary interventional neuroradiology centre.

MATERIALS AND METHODS

This prospective, single-arm study assessed 32 aneurysms treated over a 21-month time period from the time of procedure to 6 months post-procedure. Data collected included patient demographics, aneurysm features and intraprocedural and 6-month post-procedural complications.

RESULTS

The mean age of the cohort was 58.8 ± Standard Deviation 8.5 years. Twenty-eight aneurysms were treated electively and four acutely. The elective cases received dual antiplatelet therapy post-procedure. The acute cases received single antiplatelet therapy post-procedure. Of the target aneurysms, 16/32 (50%) were small (<10 mm), 13/32 (41%) were large (10-25 mm) and 3/32 (9%) were giant (≥25 mm). There was no mortality in the series. There were two periprocedural complications (2/32, 6.2%): a stroke and a dissection. There were no post-procedural complications. At 6 months post-procedure, satisfactory occlusion (defined as Raymond-Roy 1 or 2) was achieved in 90.6% and 93.8% by way of magnetic resonance angiography and digital subtraction angiography assessment, respectively. There was no implant migration, no significant intraluminal hyperplasia or in-stent stenosis and no cases of aneurysm recurrence.

CONCLUSION

The Pipeline Shield has an excellent 6- month safety profile with an acceptable rate of intraprocedural complications, no post-procedure complications and no mortality in this case series of 32 acute and elective cases.

Assessment of Femoral Artery Bifurcation Level with Conventional Angiography

Introduction The common femoral artery (CFA) is the optimal access point for femoral arterial puncture. A higher or lower puncture can result in various vascular complications and by the proper definition of the femoral arterial bifurcation level and the optimal puncture point such complications can potentially be avoided. In the literature, little data is available about the frequency of femoral artery bifurcation and the relationship between the bifurcation level of one artery and its contralateral counterpart in our part of the world. Methods We performed a prospective study from April 2016 to September 2016 to define the frequency of bifurcation of the CFA in relation to the femoral head and the relationship between bilateral CFA bifurcations, with bilateral femoral angiography on 579 patients undergoing routine coronary angiography. Results The frequency of normal/low, high, and very high femoral bifurcations was 66%, 26%, and 8%, respectively. There was no significant difference in the bifurcation of CFA between the two sides (p = 0.51). A specific bifurcation level on one side significantly increased the likelihood of the same bifurcation level on the contralateral side (odds ratio (OR) = 151.86 (51.39-448.77)). A multivariable logistic regression analysis revealed age, race, gender, height and weight, body surface area (BSA), and body mass index (BMI) were not predictive of any specific bifurcation level on either side. Conclusions The majority (two-thirds) of the individuals in the study population were with normal/low femoral bifurcation with no significant difference in bifurcation level on either side.

Spiral CT Angiography versus Aortography in the Assessment of Aortoiliac Length in Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair

Purpose:

To compare measurements of aortoiliac length obtained with spiral computed tomographic angiography (CTA) and aortography in patients undergoing endovascular aneurysm repair.

Methods:

The distances from the lower-most renal artery to the aortic bifurcation and from the aortic bifurcation to the common iliac artery (CIA) bifurcation were measured using both CTA and aortography in 108 patients with abdominal aortic aneurysms.

Results:

The level of agreement between CTA and aortography was high, with 69% of aortic and 76% of iliac measurements within 1 cm and > 90% within 2 cm of each other. Mean differences were −0.35 ± 1.20 cm and 0.25 ± 1.10 cm, respectively, for aortic and iliac lengths. Aortography overestimated renal artery to aortic bifurcation length in comparison to CTA (p = 0.003), particularly in patients with large aneurysms (> 6.5 cm) and lumen diameters > 4.5 cm (p < 0.0001). Measurements of CIA length were shorter by aortography than CTA (p = 0.02).

Conclusions:

There is a high level of agreement between CTA and aortography in the measurement of aortoiliac length, but aortography overestimates renal artery to aortic bifurcation length in patients with large-diameter aneurysms and wide aneurysm lumens. CTA is sufficiently accurate in the majority of cases to be used as the sole basis for the construction of endovascular grafts.

Impact of Hospital Volume on Outcomes of Lower Extremity Endovascular Interventions (Insights from the Nationwide Inpatient Sample [2006 to 2011])

Our primary objective was to study postprocedural outcomes and hospitalization costs after peripheral endovascular interventions and the multivariate predictors affecting the outcomes with emphasis on hospital volume. The study cohort was derived from Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2006 to 2011). Peripheral endovascular interventions were identified using appropriate International Classification of Diseases, Ninth Revision diagnostic and procedural codes. Annual institutional volumes were calculated using unique identification numbers and then divided into quartiles. Two-level hierarchical multivariate mixed models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and postprocedural complications. Amputation rates and hospitalization costs were also assessed. Multivariate analysis (odds ratio, 95% confidence interval, p value) revealed age (1.46, 1.37 to 1.55, p <0.001), female gender (1.28, 1.12 to 1.46, p <0.001), baseline co-morbidity status as depicted by a greater Charlson co-morbidity index score (≥2: 4.32, 3.45 to 5.40, p <0.001), emergent or urgent admissions(2.48, 2.14 to 2.88, p <0.001), and weekend admissions (1.53, 1.26 to 1.86, p <0.001) to be significant predictors of primary outcome. An increasing hospital volume quartile was independently predictive of improved primary (0.65, 0.52 to 0.82, p <0.001 for the fourth quartile) and secondary (0.85, 0.73 to 0.97, 0.02 for the fourth quartile) outcomes and lower amputation rates (0.52, 0.45 to 0.61, p <0.001). A significant reduction hospitalization costs ($-3,889, -5,318 to -2,459, p <0.001) was also seen in high volume centers. In conclusion, a greater hospital procedural volume is associated with superior outcomes after peripheral endovascular interventions in terms of inhospital mortality, complications, and hospitalization costs.

Evaluation of the method of hemostasis after femoral arterial puncture

[Purpose] This study assessed the advantages and shortcomings of methods for hemostasis in patients who had received angiography after femoral arterial puncture using manual, compression device, or a combination of manual compression and a compression device. In addition, the success rates, complications, etc, were analyzed. [Subjects and Methods] One hundred and eighty patients who had undergone angiography after femoral arterial puncture were divided into three groups according to the method of hemostasis. For group A, immediately after angiography, an Angio-Seal device was placed in the puncture area and compressed using a compression device. For group B, after angiography, the puncture area was compressed with the hands directly. For group C, the puncture area was compressed using a compression device for approximately 10 min, and the puncture area was then compressed with the hands. In each group, the following correlations were analyzed: the time to hemostasis after angiography and gender, the time to hemostasis of each generation and the hemoglobin value, and platelet value and the time to hemostasis. [Results] The results showed a similar time to hemostasis regardless of gender or generation. The correlation between the hemoglobin value, platelet value, and the time to hemostasis were not significant. Group A showed the shortest mean time to hemostasis of the three groups (20.37 ± 8.23 min). No complications caused by the hemostasis method were detected in group B. Group A showed the highest incidence of complications caused by hemostasis. [Conclusion] Overall, hemostasis performed mutually is safe and effective for patients according to their condition.

One of the most urgent vascular circumstances: Acute limb ischemia

Acute limb ischemia is a sudden decrease in limb perfusion that threatens limb viability and requires urgent evaluation and management. Most of the causes of acute limb ischemia are thrombosis of a limb artery or bypass graft, embolism from the heart or a disease artery, dissection, and trauma. Assessment determines whether the limb is viable or irreversibly damaged. Prompt diagnosis and revascularization by means of catheter-based thrombolysis or thrombectomy and by surgery reduce the risk of limb loss and mortality. Amputation is performed in patients with irreversible damage. Despite urgent revascularization, amputation rate is 10%–15% in patients during hospitalization, mostly above the knee, and mortality within 1 year is 10%–15% due to the coexisting conditions.

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

OBJECTIVE

This study investigated the safety and effectiveness of the infrainguinal use of the AngioJet rheolytic mechanical thrombectomy system (Possis Medical, Minneapolis, Minn) for the treatment of acute infrainguinal thromboembolism occurring during lower limb revascularization procedures.

METHODS

For the interval between January 2000 and January 2011, our hospital's database was meticulously searched for all patients with acute thromboembolism that occurred during lower limb angioplasty, with or without stenting procedures, who were treated with infrainguinal AngioJet thrombectomy. Baseline patient demographics and procedural details were analyzed. Primary end points included technical success, defined as the complete revascularization of the acutely occluded vessel; clinical success, defined as the absence of death or amputation ≤ 60 days; and procedure-related complication. Secondary end points included embolized vessel primary patency and overall patient survival.

RESULTS

During this 12-year period, 3147 peripheral percutaneous procedures of angioplasty, with or without stenting, were performed in our department. Intraoperative, clinically, and angiographically evident thromboembolism occurred in 18 of 3147 procedures (0.57%), and 14 (77.7%) were managed using the AngioJet thrombectomy system. In total, 22 arteries were treated (13 infrapopliteal, 3 femoropopliteal, and 6 popliteal arteries). All patients had a completion angiogram for the assessment of the runoff vessels' status. Technical and clinical success occurred in 13 of 14 (92.8%). Adjunctive local thrombolysis or clot trapping, or both, with stenting was used in 64.3% and 42.8% of the procedures, respectively. Mean time follow-up was 38.1 ± 49.0 months. The 1-year embolized vessel primary patency rate was 50.9%, and the survival rate was 53.5% up to 11.5 years of follow-up, as estimated by Kaplan-Meier analysis. The 1-year limb salvage rate was 92.3%. There were no procedure-related minor amputations and one (7.1%) procedure-related major above-knee amputation.

CONCLUSIONS

The use of AngioJet rheolytic thrombectomy and adjunctive local thrombolysis or stenting, or both, under filter protection, is safe and effective for the management of severe thromboembolic complications occurring in the femoropopliteal and infrapopliteal arteries during peripheral endovascular procedures.

Radioembolization complicated by dissection of the common femoral artery

The common femoral artery is the most frequently used access site for angiographic procedures in interventional radiology. Potential complications of common femoral arteriotomy include hematoma formation, pseudoaneurysm, uncontrolled groin or retroperitoneal bleeding, acute arterial occlusion, dissection, and arteriovenous fistula formation. In a case such as the one described here, with a common femoral artery dissection with intraluminal thrombus and vessel occlusion, the complication may have occurred at the time of access or at the time of closure, with both procedure-associated and patient-specific risk factors affecting the overall risk of complications. Though some studies have shown an increased risk of complications with the use of arterial closure devices, others have found no increase. In any patient with symptoms following a femoral arteriotomy, rapid diagnosis and treatment is necessary to avoid further complications. Both patient-specific and procedure-associated risk factors should be considered prior to arteriotomy and usage of an arterial closure device.

Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia

Percutaneous catheter-directed intra-arterial thrombolysis is a safe and effective method of treating acute and subacute lower limb ischemia, as long as accurate patient selection and procedural monitoring are ensured. Although larger, controlled trials are needed to establish the role of PTDs in ALI, mechanical thrombectomy could currently be applied combined with lytic infusion in selected cases where rapid recanalization is required or as a stand-alone therapy when the administration of thrombolytic agents is contraindicated.

Incidence and risk factors of vascular complications following endovascular treatment of peripheral arterial disease via the popliteal artery

To evaluate vascular complications associated with endovascular treatment (EVT) of peripheral arterial disease (PAD) through the popliteal artery and to identify the risk factors for these complications. Between November 2005 and January 2009, 63 patients with PAD received EVT via the popliteal artery. Retrograde (n = 58) and antegrade (n = 5) transpopliteal procedures were performed to target 77 lesions, including 12 distal to the trifurcation. Thirty-five punctures were performed under ultrasound guidance and 7 under angiographic guidance; 21 punctures were performed without any guidance. Vascular complications were evaluated by physical examination and duplex ultrasonography. Vascular complications at the popliteal puncture site occurred in 8 patients (12.7%): 6 hematomas and 2 arteriovenous fistulas (AVF). Seven of 24 patients receiving hemodialysis (HD) (29%) had significantly higher complications (P = 0.004) compared with 1 of 39 patients not receiving hemodialysis (non-HD) (2.6%). HD alone was also a significant risk factor for hematoma (P = 0.010). Both AVF occurred in HD patients (P = 0.141), and one occurred despite ultrasound-guided puncture. Ultrasound-guided puncture showed no significant improvement in reducing both complications. The combination of antiplatelet and anticoagulant therapy showed no statistical significance in overall complications. In non-HD patients, the transpopliteal approach in the EVT of PAD seems to be safe. More attention should be paid to HD patients when using the transpopliteal approach due to a higher complication rate.

Peripheral arterial disease: current perspectives and new trends in management

Peripheral arterial disease (PAD) is defined as an arterial brachial index (ABI) of < or =0.90 in the lower extremities and results from a narrowing of the arteries as a result of progressive atherosclerosis. PAD affects 12-20% of Americans aged 65 years or older; however, most are asymptomatic and many do not seek treatment. Improved awareness and education in both the general population and among health care providers about these modifiable risk factors has the potential to improve general health and decrease morbidity and mortality secondary to atherosclerotic vascular disease.

Impact of intravascular ultrasound for the treatment of calcified infrarenal aortic stenosis: a case report study

We report two cases of heavily calcified infrarenal aortic stenosis that were successfully treated by intravascular ultrasound- (IVUS)-guided stenting. Two middle-aged women visited our hospital due to intermittent claudication. Diagnostic arteriography revealed possible infrarenal aortic stenosis even though the findings were equivocal. IVUS demonstrated heavily calcified atherosclerotic lesions and allowed the accurate assessment of the types and extents of the lesions to be treated in both cases. The patients successfully underwent stent implantation according to the findings of IVUS. IVUS significantly contributed to the interventional successes.

Percutaneous transluminal angioplasty in recurrent necrotizing enterocolitis--a case report

A 35-week gestation male neonate had 3 episodes of necrotizing enterocolitis (NEC), the first of which was managed surgically. Two further episodes of NEC were treated by medical management. Angiography then identified a stricture at the origin of the superior mesenteric artery. Percutaneous transluminal angioplasty successfully dilated the stenosis, and no further episodes of NEC occurred. Eight years later, the child exhibits a mild spastic diplegia and is thriving with no gastrointestinal disturbances. Angioplasty is technically feasible in the neonate and may be a treatment option in recurrent NEC associated with visceral arterial stenosis.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

INTRODUCTION

We evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.

METHODS

A total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.

RESULTS

The procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.

CONCLUSION

Our experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

Outpatient angioplasty and stenting facilitated by percutaneous arterial suture closure devices

AIM

To review our practice of outpatient percutaneous vascular interventions facilitated by an arterial suture device.

MATERIALS AND METHODS

A retrospective review of all patients attending this tertiary centre for iliac or femoral intervention was undertaken between February 2001 and December 2004. All patients who underwent angioplasty or stenting had their puncture sites closed using a Perclose suture. Patients were kept flat for 15min and allowed to fully mobilize at 60min. Puncture sites were scored for visible bruising, haematoma and pain at discharge and on outpatient follow-up. Patient preference for future outpatient treatment was assessed.

RESULTS

Fifty-seven outpatients underwent 81 punctures. Forty-eight (84%) patients underwent iliac angioplasty; of those 42% underwent stent placement. Six patients (10%) required inpatient admission, five secondary to failed suture deployment. One patient had a non-closer-related puncture site intimal flap occlusion successfully repaired at surgery. Fifty-one (90%) patients discharged with a mean time of 157min (60-280min). Forty-six (92%) patients had no visible bruising or palpable haematoma on discharge. No patient had a haematoma greater than 2.5cm. No discharged patient required readmission. Thirty percent reported a moderate to severe groin pain score (2-5/5) at discharge, increasing to 40% at follow-up. Forty-seven (98%) of the 48 patients, who expressed a preference, would be happy to undergo outpatient treatment again.

CONCLUSION

Outpatient treatment is feasible, well tolerated and preferable to patients, but 10% will require inpatient admission. A planned post-procedure analgesia regimen or advice should be considered.

Ultrasound-Guided Retrograde Popliteal Artery Catheterization: Experience in 174 Consecutive Patients

PURPOSE

To assess the safety and efficacy of ultrasound (US) guidance during retrograde popliteal artery catheterization (RPAC) and identify the risk factors for late hemostasis and complications.

METHODS

A retrospective review was undertaken of consecutive patients who underwent grayscale US-guided RPAC during the last 8 years. Chart review identified 174 patients (150 men; mean age 61+/-10 years, range 37-84) with 247 iliofemoral lesions, which were treated via US-guided RPAC. Complications were classified as puncture-related versus angioplasty-related and major versus minor. Risk factors for complications and late hemostasis were evaluated with logistic and linear regression analyses, respectively.

RESULTS

All 234 US-guided RPACs were technically successful. No arteriovenous fistula (AVF) or dissection/thrombosis of the popliteal artery was observed. The mean time to hemostasis was 6.9+/-2.3 minutes. The presence of femoral stenosis (versus occlusion) and use of large (6 to 7-F) sheaths were significant risk factors for late hemostasis. In 234 procedures, 15 (6.4%) complications developed; 10 (4.3%) were puncture-related (3 major, 7 minor) and 5 (2.1%) were angioplasty-related (3 major, 2 minor). Intra-arterial fibrinolysis was found to be the only significant risk factor for overall and puncture-related complications.

CONCLUSIONS

Our results suggest that US-guided RPAC is at least as safe as other RPAC methods described in the literature. In contrast to generally held concerns, hemostasis is easy to obtain, and multiple punctures and the use of large sheaths appear safe. These results should be taken into consideration during the selection of an access site for endovascular treatment of superficial femoral artery and tandem iliofemoral lesions.

Long-term outcomes and predictors of iliac angioplasty with selective stenting

OBJECTIVE

To review our 11-year experience of iliac angioplasty with selective stenting and to evaluate the safety, short- and long-term patency, clinical success rates, and predictive risk factors in patients with iliac artery occlusive disease.

METHODS

From August 1993 to November 2004, 151 iliac lesions (149 stenoses, 2 occlusions) in 104 patients were treated by percutaneous transluminal angioplasty (PTA). The patients had chronic limb ischemia described as disabling claudication (the Society for Vascular Surgery clinical category 2 or 3) in 76 (50%), rest pain (category 4) in 38 (25%), and ulcer/gangrene (category 5) in 37 (25%). Forty-six limbs (30%) were treated with concomitant infrainguinal endovascular (36, 24%) or open procedures (10, 6%). Thirty-four limbs (23%) had one or more stents placed for primary PTA failure, including residual stenosis (> or =30%), mean pressure gradient (> or =5 mm Hg), or dissection (stent group); whereas, 117 limbs (77%) underwent PTA alone (PTA group). The affected arteries treated were 28 (19%) common iliac, 31 (20%) external iliac, and 92 (61%) both arteries. According to TransAtlantic Inter-Society Consensus (TASC) classification, 39 limbs (26%) were in type A, 71 (47%) in type B, 36 (24%) in type C, and 5 (3%) in type D. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed.

RESULTS

There was no perioperative death. Total complication rate was 0.7% (one groin hematoma). The mean follow-up was 21 months (median, 10; range, 1 to 94 months). Only 9 (8%) of 117 of the PTA group had subsequent stent placement for recurrent stenosis. The iliac lesions were more severe and extensive in the stent group than those in the PTA group according to TASC classification (Mann-Whitney U test [M-W], P < .0001) and anatomic location (M-W, P = .0019). The technical success rate was 99%, and the initial clinical success rate was 99%. Overall, the cumulative primary patency rates at 1, 3, and 5 years were 76%, 59%, and 49% (Kaplan-Meier [K-M]). The cumulative assisted primary and secondary patency rates at 7 years were 98% and 99% (K-M). The mean number of subsequent iliac endovascular procedures was 1.4 per limb in patients with primary failure of iliac angioplasty/stenting. The continued clinical improvement rates at 1, 3, and 5 years were 81%, 67%, and 53% (K-M). The limb salvage rates at 7 year were 93% (K-M). Of 15 predictor variables studied in 151 iliac lesions, the significant independent predictors for adverse outcomes were smoking history (P = .0074), TASC type C/type D lesions (P = .0001), and stenotic ipsilateral superficial femoral artery (P = .0002) for the primary patency rates; chronic renal failure with hemodialysis (P = .014), ulcer/gangrene as an indication for PTA (P < .0001), and stenotic ipsilateral superficial femoral artery (P = .034) for the continued clinical improvement (K-M, log-rank test and Cox regression model).

CONCLUSIONS

Although the primary patency rates were not high, the assisted primary and secondary patency rates were excellent without primary stenting. Overall, >70% of iliac lesions were treated successfully with PTA alone. The results of this study show that selective stenting offers satisfactory assisted primary and secondary long-term patency after iliac angioplasty. Patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/gangrene, smoking history, and chronic renal failure with hemodialysis should be followed carefully after endovascular iliac revascularization. These risk factors could be considered indications for primary stenting, although further studies are needed to confirm this.

Percutaneous interventional reconstruction of the iliac arteries: primary and long-term success rate in selected TASC C and D lesions

We report the primary and long-term outcome of patients with selected TransAtlantic Inter-Society Consensus (TASC) C or D lesions of the iliac arteries after percutaneous interventional reconstruction. Between 1999 and 2001, 89 patients with peripheral arterial disease categorized as TASC C (n=37) and D (n=52) underwent percutaneous interventional reconstruction and stent implantation. Patients were followed for 1-62 months (mean 36 months). Patency rates were assessed by Duplex ultrasound and ankle-brachial index (ABI) measurement. The primary technical success rate was 96.9% with an overall complication rate of 5.6%. The ABI improved from an average of 0.51+/-0.15 before intervention to 0.79+/-0.16 on the day following intervention and to 0.81+/-0.17 within 3 years after intervention. Clinical improvement was observed in 97.3% of the patients in the TASC C group and in 88.5% in the TASC D group. Eighty of 89 patients (89.9%) remained patent at 3-year follow-up. In five patients the reintervention was successful. The secondary patency rate was 95.5%. The patency rates were similar in our selected TASC C and D patients to those so far published for TASC A and B, with low complication rates. Therefore, percutaneous intervention can be recommended for these patients.

Thrombolysis in the Management of Lower Limb Peripheral Arterial Occlusion—A Consensus Document

The aim of this paper is to develop an intercontinental consensus on the use of thrombolytic therapy in occlusive peripheral arterial disease affecting lower limbs. A working party of self-designated angiologists, hematologists, interventional radiologists, and vascular surgeons of Europe and North America convened at 4 closed meetings. All published data known to any of the participants was entered into discussion. The working party discussed the topics outlined in this paper and a first draft was prepared in segments by members of the working party, discussed, and further revised into an interim report. It was then circulated to a number of Societies for their input. A final meeting of the Working Party together with delegates of the Societies collaborated on the definitive version of the text. The Party appreciates that in many areas the scientific evidence is not yet available. Nevertheless, it was felt that enough practical and scientific data were available to establish recommendations for clinical practice as well as for reporting results of thrombolytic therapy, which could be updated as later evidence became available. The guidelines apply only to drugs currently available for clinical use. The data are also considered to be sufficiently cogent that regulatory agencies should move to approve thrombolytic agents for intra-arterial therapy of acute lower extremity ischemia.

Complications of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure: a case-controlled study

PURPOSE

To evaluate the incidence and types of complications encountered with use of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure in a retrospective case-controlled study.

MATERIALS AND METHODS

The authors identified 100 consecutive patients, 15 men and 85 women 21-85 years of age (mean, 50 years), between December 2000 and July 2001 in whom the Closer percutaneous suture-mediated closure device was used during 65 uterine artery embolization (UAE) procedures, 11 hepatic chemoembolization procedures, nine diagnostic angiography procedures, seven peripheral vascular interventions, six visceral arterial interventions, and two thrombolysis procedures. An age-, sex-, and procedure-matched control population was identified in which manual compression was performed. Procedure reports and clinical charts were reviewed for the presence of puncture-site complications, as categorized according to Society of Interventional Radiology reporting standards, and for risk factors and comorbid conditions (hypertension, diabetes, stroke, smoking, and coronary artery disease). Follow-up visits and imaging studies were reviewed for patients with complications.

RESULTS

In the Closer group, there were seven device failures, four minor complications, and three major complications. Minor complications included two groin hematomas and two cases of persistent pain at the arteriotomy site. Three major complications consisted of two cases of external iliac artery dissection, one with distal embolization, and one case of common femoral artery (CFA) occlusion and distal embolization. All major complications occurred in women undergoing UAE. One patient required thromboendarterectomy and patch angioplasty to repair the CFA occlusion, as well as amputation of a gangrenous toe. In the manual-compression group, there was one minor complication (a groin hematoma) and no major complications. There were significantly more complications in the Closer group than in the manual compression group (P =.02).

CONCLUSIONS

Significantly more complications were associated with use of a percutaneous suture-mediated closure device than with manual compression for arteriotomy-site hemostasis. Major complications and associated morbidity may be seen with use of percutaneous suture-mediated closure devices. In particular, an unexpectedly high frequency of device-related complications was demonstrated in young women undergoing UAE.

Results of a European multicentre iliac stent trial with a flexible balloon expandable stent

PURPOSE

to determine the 12 months success rate with a balloon expandable, flexible stainless steel stent in iliac artery obstructions.

MATERIALS AND METHODS

one-hundred and twenty-six consecutive patients with iliac obstructive disease and who demonstrated an unsatisfactory angioplasty result with a post-dilatation gradient of at least 10 mmHg, or a primary occluded lesion were included in the study. Follow-up was by Doppler sonography, ankle pressures with and without exercise and clinical parameters.

RESULTS

after stent placement, the mean percentage diameter stenosis decreased from 79 to 4%, with a mean intra-arterial pressure gradient of 3 mmHg. Primary stent patency was 94% at 6 months and 89% at 12 months. Primary clinical result at 6 months was 88% and at 12 months 81%. Primary assisted clinical result (after re-pta) at 6 and 12 months was 89 and 86%, respectively. The Ankle Brachial Index (ABI) after exercise at 1 month follow-up was reduced from 0.88 to 0.75, with minor deterioration at 6 months to 0.72, and at 12 months to 0.68. The 1, 6, and 12 months follow-up Piek Systolic Velocity (PSV) ratios across the stented lesions remained stable at a mean of 1.4, 1.6, and 1.6, respectively. However, respectively 44, 39 and 34% of the patients still experienced symptoms of claudication.

CONCLUSIONS

the results presented here support the suggestion stenting to be an effective device in the treatment of iliac artery obstructive disease. This study also, confirms other study results concerning haemodynamic patency after iliac stenting on the indication of a 10 mmHg pressure gradient after pta and the discrepancy between good haemodynamic patency and clinical result.

Pharmacotherapy for peripheral arterial disease: emerging therapeutic options

Although endovascular therapy has revolutionized the management of patients with peripheral arterial disease (PAD), noninterventional regimens, such as structured exercise therapy, atherosclerotic risk factor modification, and pharmacotherapy, are effective in patients suffering from mild-to-moderate PAD and intermittent claudication (IC). For more than a decade, the only pharmacologic therapy for IC available in the United States was pentoxifylline, which had demonstrated superiority in improving walking distances but offered minimal clinical benefit. Recently, basic research into the pathophysiology of IC has led to the development of cilostazol, a new pharmacologic agent approved for treatment of this condition in 1999. Ongoing research in the use of angiogenic growth factors has further broadened the range of potential alternatives to treatment in patients with PAD. Revascularization procedures, including nonsurgical and surgical techniques, can thus be reserved to improve patency and reduce the risk of limb loss in patients with PAD and IC with more severe impairment.

Value of MR angiography before percutaneous transluminal renal artery angioplasty and stent placement

PURPOSE

To determine the benefit of preprocedural three-dimensional gadolinium (Gd)-enhanced magnetic resonance (MR) angiography before percutaneous transluminal renal artery angioplasty and stent placement (PTRA/S) in terms of procedural success, iodinated contrast material load, and procedure duration.

MATERIALS AND METHODS

Over an 18-month period, 39 patients underwent attempted percutaneous renal angioplasty with or without stent placement. A total of 48 renal arteries were treated (40 cases of atherosclerosis, one of stent restenosis, five of fibromuscular dysplasia, and two of transplant stenosis). Preprocedural Gd-enhanced MR angiography was available in 16 procedures (41%). Procedural outcome, complications, iodinated contrast material load, number of diagnostic angiographic runs, and total procedure duration were each compared between two subgroups: patients who had preprocedural Gd-enhanced MR angiography ("prior MR angiography group") and those who did not ("no MR angiography" group).

RESULTS

All procedures were technically successful. The two groups were equivalent in terms of age and disease pattern. However, technical complexity of the procedure was judged to be high in five of 16 procedures in the prior MR angiography group compared to three of 23 procedures in the no MR angiography group (P =.16). Bilateral or dual interventions were performed in six of 16 procedures in the prior MR angiography group compared to three of 23 in the no MR angiography group (P =.075). Iodinated contrast material load was significantly lower in the prior MR angiography group than in the no MR angiography group (68.7 mL +/- 28.4 vs 119.1 mL +/- 49.2 mL;P <.0008). The number of diagnostic angiographic runs before interventions were also significantly lower in the prior MR angiography group (1.2 +/- 0.4 vs 2.6 +/- 0.7; P <.0001). Overall procedure duration was comparable between the two groups (91.9 +/- 47.8 vs 112.2 +/- 49.4;P =.2).

CONCLUSION

Preprocedural planning with use of Gd-enhanced MR angiography significantly reduces the iodinated contrast material requirement during percutaneous renal artery interventions. It can also significantly shorten procedure duration.

Common femoral artery anatomy is influenced by demographics and comorbidity: implications for cardiac and peripheral invasive studies

We assessed the angiographic size of the common femoral artery (CFA) and the influence of demographics and comorbidites. In addition, the location of the CFA bifurcation and the site of femoral puncture were also assessed. Consecutive CFA angiograms (n = 200) were prospectively analyzed. CFA diameter was 6.9 +/- 1.4 mm and length 43.3 +/- 16.2 mm. By multivariate analysis, only diabetes (P < 0.001), female gender (P < 0.0005), and small body surface area (P < 0.01) predicted small vessel size. Vessel length correlated with patient height (P < 0.0005). CFA bifurcation occurred at or below the femoral head center in 98.5%. The femoral puncture was into a vessel other than the CFA in 13%, and 54% of punctures were in a less than ideal anatomical location. In conclusion, the CFA is a relatively small diameter vessel, particularly in diabetics and women. Puncture above the femoral head center and below the superior margin of the acetabulum accurately predicts an ideal puncture site. Thus, routine fluoroscopic guidance should be considered. Cathet Cardiovasc Intervent 2001;53:289-295.

Early mobilization following angioplasty

AIM

To assess the incidence of puncture site complications in in-patients undergoing early mobilization following angioplasty with a view to performing day case angioplasty.

MATERIALS AND METHODS

One hundred and twenty-eight patients undergoing peripheral and renal angioplasty using a sheath size of up to 6 French were recruited prospectively. The mobilization protocol consisted of supine bed rest for 2 h, followed by gradual mobilization, so that the patient was ambulant 4 h after the procedure. Mobilization was delayed if clinically appropriate. Puncture sites were scored for discomfort, paraesthesia, visible bruising and palpable haematoma after groin compression and the following morning.

RESULTS

One hundred and forty-four puncture sites were studied. There were 44 haematomas in total, of which 37 (26%) were less than 2.5 cm and seven (4.9%) were between 2.5 cm and 7.5 cm. Four patients (2.8%) had visible bruising greater than 7.5 cm. No patient assessed discomfort higher than moderate at any stage. Mobilization was delayed in 15 patients. In 11 this was due to puncture site oozing, haematoma in one, two were hypertensive and one required surgery for limb ischaemia. All complications occurred within 4 h of angioplasty. No patient required surgery or transfusion for haemorrhagic complications.

CONCLUSION

Mobilization at 4 h was successful in 90% of cases but 10% require more prolonged bed rest. No delayed complications occurred. These results suggest that day case angioplasty is feasible in most cases.Butterfield, J. S. (2000). Clinical Radiology55, 874-877

Vascular imaging and intervention in peripheral arteries in the diabetic patient

Diabetic patients are four times more likely to develop peripheral vascular disease than the general population. This disease is likely to be more aggressive, with five times more patients developing critical limb ischaemia. Early diagnosis and treatment allows up to 80% of these patients to have some form of surgical or endovascular re-vascularisation. The primary imaging modalities to be used should be duplex ultrasound followed by angiography. Magnetic resonance angiography, however, holds out promise for the future as being a good method of non-invasive imaging. Endovascular (interventional radiological) procedures have a major role to play in treatment of vascular stenoses and occlusions. Thrombolytic agents can be used to dissolve thrombus within occluded vessels and so restore patency. Percutaneous transluminal angioplasty is of value in dilating the stenotic lesions within the vessels and so restoring normal blood flow. Endovascular stents may be inserted to ensure longer term patency. There is indirect evidence to suggest that the outcomes of endovascular procedures in the diabetic patient are less good than those in the general population, but nevertheless such procedures may save the diabetic patient from primary amputation and allow healing of ischaemic ulcers.

Complicated stent supported cerebrovascular angioplasty: case analyses and review of literature

BACKGROUND

Hemodynamic lesions of the cervicocerebral vasculature are currently being treated with stent supported percutaneous transluminal angioplasty. These procedures have met with increasing success when compared to the risks and morbidity of more invasive surgical approaches. The versatility of stent-supported angioplasty as a primary therapeutic modality is examined in the following complex cases.

CASE DESCRIPTION

We present four cases involving cervical angioplasty with emergent or adjunctive stent placement. Two cases involved the subclavian arteries, whereas the others involved the vertebral and internal carotid arteries. In our experience, complications of cervicocerebral artery angioplasty have been successfully managed by stent placement.

CONCLUSION

Our cases demonstrate the emerging role of cervical angioplasty and stent implantation as a successful therapeutic modality, highlighted in these complex cases.