Cost incentives for peripheral angioplasty

Hospital costs and length of stay for 86 patients with peripheral vascular disease treated by bypass or percutaneous transluminal angioplasty (PTA) were assessed. The length of stay averaged 4-4.5 times longer, and the total hospital charge was 3-3.7 times greater, for bypass than for PTA. These charges are discussed in relation to current diagnosis-related groups (DRGs) and the allowed reimbursement from the Federal Prospective Payment System. In appropriately selected patients with peripheral vascular disease, PTA should be the treatment of choice from both medical and financial points of view.     

Safety of outpatient arterial stenting.

OBJECTIVE: To assess the safety of performing iliac arterial stenting as an outpatient procedure. METHODS: Retrospective analysis of safety including all patients referred for elective iliac arterial stenting over a 1-year period. Sources of data for the analysis included pre- and post-stenting vascular surgical consultation records, hospital case notes, diagnostic and interventional angiography reports, computerized laboratory data, nursing records from our angiography holding area, and the results of routine post-stenting telephone follow-up. RESULTS: There were 29 outpatient iliac stenting procedures in 28 patients (19 men and 9 women, age range 41.0 to 79.8 years, mean age 66.1 years). Of these 29 procedures, 17 involved unilateral iliac stenting, and 12 involved bilateral iliac stenting. Adjunctive renal artery angioplasty was performed in 1 patient and internal iliac angioplasty and stenting were performed in 2 patients. A total of 51 stents were deployed through 42 femoral punctures via introducer sheaths ranging in size from 6 to 8 French. Percutaneous hemostatic closing devices were used in 6 punctures. Two patients required overnight inpatient observation for moderate-size hematomas; these had no clinical sequelae. All others were discharged safely 5 to 6 hours after sheath removal. No clinically significant sequelae were identified in any patient. CONCLUSION: Arterial stenting can be performed safely on an outpatient basis.     

Percutaneous transluminal angioplasty of peripheral bypass stenoses

Purpose: To assess the success of percutaneous transluminal angioplasty (PTA) in treating peripheral bypass stenoses. Methods: Patients who received a femoropopliteal or femorocrural bypass graft for limb ischemia were included in a duplex surveillance program. If duplex ultrasound revealed a short (<2 cm) severe (peak systolic velocity ratio ≥ 4.5) stenosis, patients were scheduled for arteriography and PTA. Fifty-eight peripheral bypass stenoses in 39 grafts in 37 patients were treated with PTA. The cumulative primary patency of treated stenoses was calculated. Results: During the first year after PTA 31 (53%) treated lesions remained patent, 15 (26%) lesions restenosed at a median interval of 5.0 (range 1–12) months and 4 (7%) bypasses occluded. The cumulative primary patency of 58 treated graft stenoses at 1 year was 60% [95% confidence interval (CI) 46%–74%] and 55% (95% CI 41%–70%) at 2 years. Graft body stenoses showed a better 2-year cumulative primary patency (86%; 95% CI 68%–100%) compared with juxta-anastomotic lesions (45%; 95% CI 29%–62%; p < 0.05). Conclusion: PTA is justifiable as the initial treatment of peripheral bypass stenoses. Nevertheless, the restenosis rate is rather high, especially in juxta-anastomotic lesions. Continuation of duplex surveillance after PTA and timely reintervention is recommended.     

Assessment of heparin anticoagulation during peripheral angioplasty.

The amount of heparin administered during peripheral angioplasty procedures is controversial and varies greatly among angiographers. Complications may result from both excessive and insufficient anticoagulation. The authors characterized the anticoagulant response to heparin in patients undergoing angioplasty by means of the activated clotting time (ACT). The ACT was measured in 64 patients who underwent lower extremity angioplasty. There was a linear relationship between heparin dose and ACT (P = .0001), but the slope of this relationship varied from patient to patient (R2 = .232). The response to heparin was blunted in one patient with thrombosis, but it was not exaggerated in patients with hematomas. Heparin anticoagulant response is highly variable, and heparin administration should be individualized according to ACT to produce a desired level of anticoagulation. Use of the ACT is a convenient and reproducible means of monitoring heparin administration and may increase safety and efficacy during peripheral angioplasty.     

The complication rate of percutaneous peripheral balloon angioplasty

One thousand six hundred and forty-two vessel segments (46% iliac, 54% femoro-distal) in 1141 patients have undergone percutaneous peripheral balloon dilatation at the Northern General Hospital, Sheffield over a 9 year period. Forty-two significant complications were encountered in all; 28 of these were occlusive and half of these were treated by angioplasty itself, either by thrombolysis or catheter suction. There was one case of distal ischaemia attributed to cholesterol embolisation which led to death (Gaines et al., 1988). There were two cases of perforation and haematoma requiring surgery, one retroperitoneal haemorrhage and one false aneurysm. One diabetic patient developed septicaemia following successful PTA for an ischaemic foot and died. One case each of bowel ischaemia, cerebrovascular accident and myocardial infarction occurred within 24 h of the angioplasty procedure, but there was no clear causal relationship. Arterial wall dissection or perforation per se was not considered a complication unless it progressed to haemorrhage or vessel occlusion. There were three cases of femoral nerve damage causing sensory loss in the thigh, two of which were permanent. Four hundred and thirty-five procedures were performed in patients with rest ischaemia. Of these, 2.8% developed complications requiring surgery, but only 0.9% required reconstructive bypass surgery. For intermittent claudication 1207 procedures were performed, 0.7% of these developed complications requiring surgery but only 0.5% required reconstructive surgery. These results justify the use of angioplasty in the treatment of intermittent claudication and in poor risk patients with threatened limb loss.     

Laser angioplasty of peripheral vessels: complementary procedures

From 1987 to 1991 we treated 167 peripheral arteries in 143 patients by laser-assisted balloon angioplasty using a Neodymium YAG laser. Embolism fo1lowing or accompanying laser angioplasty was treated by aspiration and local lysis with urokinase in 10 cases. To improve long term results balloon dilatation of stenoses of the proximal vessel was performed in 36 cases (5 iliac arteries, 30 femoral arteries, 1 bypass), and of the distal vessel in 31 (16 femoropopliteal arteries, 15 crural arteries). Percutaneous transluminal angioplasty of recurrent stenosis within the recanalised segment was necessary in 11 patients. It was also possible 1o reopen 10 reocclusions, 6 by aspiration and local lysis and 4 by a second laser angioplasty. Both the high technical success rate (90.4%) and the good long term results (cure rate after 3 years 66.8%) are due in part to complementary procedures.     

Laser angioplasty of peripheral arteries: An epilogue?

This review gives a short overview of the results of 15 years of experimental and clinical work on laser angioplasty. Experimentally, photothermal and photomechanical ablation of plaque could be demonstrated. However, laser angioplasty did not cause reduction of platelet adhesion and intimai hyperplasia. Clinically, the technique of laser angioplasty was continuously improved until the initial recanalization rates and longterm patency rates in femoropopliteal artery occlusions were the same as the success rates of percutaneous transluminal angioplasty (PTA). This was proven by various randomized studies. Currently, laser angioplasty cannot be proposed as a routine procedure because it is an expensive technology. However, laser recanalization and debulking of total occlusions should be further developed, especially in combination with endoluminal graft placement.     

Complications after percutaneous transluminal angioplasty of peripheral and renal arteries

This review deals with complications after percutaneous transluminal angioplasty (PTA). First some methodologic points are discussed. It seems important to standardize the way in which complications are reported. Our own complications in peripheral and renal PTA are summarized and taken as a basis for an analysis of various types of complications. Principally these may occur at different levels: at the puncture site, at the dilatation site as well as distant and general complications. To make comparisons with surgical series relevant it is suggested that all complications and mortality within 30 days are reported.     

Long-term results of percutaneous transluminal angioplasty in a peripheral region

The authors performed, in the period of 10/1980 to 12/1985, 102 PTA interventions in 95 patients in the peripheral region. The lasting clinical improvement of early and long-term duration was expressed by the Life-table method. In the whole cohort, 95% of patients proved to be improved clinically in the early period (3 months after the intervention), while 70% of patients were improved for long-term period (up to 66 months). The authors also compare the results reached in PTA of pelvis vascular bed and femoropopliteal region. In the PTA of pelvis vascular bed, improved clinical condition in the early period was reached in 95% of patients, long-term improvement was observed in 73% of individuals. In PTA of femoropopliteal region the early period showed improvement in 96% of patients, the long-term period indicated improvement in 52% of subjects.     

Evaluation of the peripheral arteries with duplex US after angioplasty

Duplex ultrasound (US) was performed in 22 patients before and immediately after percutaneous transluminal balloon angioplasty (PTA) for peripheral artery stenoses or occlusions. Two patients underwent PTA on two occasions, and one patient underwent PTA of each lower extremity, resulting in 25 duplex US imaging pairs at a total of 40 PTA sites. The criterion for significant stenosis on duplex US studies was an increase in peak systolic velocity of at least 100% compared with the velocity in the arterial segment proximal to the lesion (velocity ratio, greater than or equal to 2.0). For 22 paired duplex US studies, pulse volume recordings or ankle-brachial indexes were obtained before and after PTA. After PTA, eight patients had residual high velocity ratios at 12 PTA sites. Only two of these patients had a residual hemodynamic stenosis as determined with post-PTA arteriography, pulse volume recordings, or ankle-brachial indexes. In this study, duplex US that was performed immediately after PTA for evaluation of residual stenosis was frequently misleading.     

Outpatient peripheral angioplasty: survey of complications and patients' perceptions

We report our experience with a total of 79 peripheral angioplasties performed in 64 patients on an outpatient basis between July 1983 and April 1985. Review of the medical files and a telephone inquiry in 58 subjects (72 angioplasties) revealed no major complications, a low rate of minor complications (1.5%), and a high degree of patient satisfaction (99%).     

Intravascular ultrasound angioplasty in peripheral arterial occlusion. Preliminary experience

Purpose: To determine if ultrasound angioplasty in a percutaneous approach was capable of recanalizing occluded arteries in acute and subacute peripheral arterial occlusions.Material and Methods: We applied an ultrasound angioplasty device in a percutaneous approach in 9 patients with peripheral arterial occlusions. All patients suffered from severe leg ischemia due to subacute thrombotic occlusions.Results: The ultrasound transmitter easily created a channel within the occlusive material. To further reduce the mass of the occlusive material, an aspiration thrombectomy was performed in all cases, leading to a complete recanalization in 7 cases. In 2 cases, a remaining stenosis was successfully dilated.Conclusion: Intravascular ultrasonic devices can be useful for recanalization of occluded peripheral arteries. In particular, if thrombolytic therapy of longer peripheral arterial occlusions fails or is contraindicated, ultrasound angioplasty may be a new approach for recanalization.     

Percutaneous transluminal angioplasty of peripheral vascular disease: A two-year experience

Over a 23-month period, 172 successful peripheral angioplasties were performed. Life-table analysis gave a two-year patency rate for the total series of 80%. The patency rate for aorto-iliac and femoral-popliteal lesions was 86% and 70%, respectively. Only one late failure occurred in the group of 44 arteries follwed for longer than eight months.     

A solution to ankle-brachial index limitations in peripheral transluminal angioplasty

Purpose

We evaluated the limitations of the ankle-brachial index (ABI) in the revascularisation of diabetic patients with critical limb ischaemia (CLI) who were undergoing peripheral transluminal angioplasty (PTA) compared with the degree of arterial stenosis and with transcutaneous oxygen tension (TcpO₂).

Materials and methods

This prospective study assessed 250 consecutive diabetic patients in whom we evaluated results of posterior tibial and dorsalis pedis Doppler, ABI, TcpO₂, and duplex scans. In total, 104 patients were considered suitable candidates for PTA.

Results

In 42% of the patients studied, ABI could either not be used (9.34% due to no signal; 14.02% because the artery could not be compressed) or was incorrect (18.7% before PTA; 15.9% after PTA). In contrast, TcpO₂ was determined in all cases. After PTA, vessel stenosis decreased from 58.33±20.07% to 21.87±13.57% (p<0.001), whereas ABI increased from 0.79±0.57 to 0.95±0.47 (p<0.001) and TcpO₂ from 27.37±10.40 mmHg to 38.23±10.25 mmHg (p<0.001). A statistical analysis revealed scant correlation between techniques (TcpO₂ and ABI) (r=0.14).

Conclusions

ABI shows significant limitations for the diagnosing and treating CLI patients compared with TcpO₂.     

Laser-assisted percutaneous angioplasty: initial clinical experience in peripheral arteries

Experimental and animal studies have shown that laser energy can vaporize intra-vascular thrombus and atheroma, suggesting that it may have a role in percutaneous angioplasty. Argon laser energy transmitted via a flexible fibre introduced through a percutaneous catheter was used in 15 patients undergoing balloon angioplasty of femoral or popliteal arteries. Of four stenoses, laser alone produced improvement of the lumen in two. Of 11 occlusions some degree of clearance of the lumen was achieved by laser in eight prior to balloon dilatation. Extravasation of contrast medium indicating wall perforation occurred in two patients, without clinical sequelae. No other complications, such as embolism, arterial spasm or toxic effects were observed. There was one acute re-occlusion, almost certainly not related to the use of laser. There have been no late complications. The ability of laser to influence favourably vascular occlusion is confirmed, but technical advances are necessary to avoid vessel wall perforation consistently and to improve the production of an adequate lumen before its potential can be fully realized.