Percutaneous transluminal angioplasty and severe limb ischaemia

OBJECTIVES: To determine the outcome and the place of transluminal angioplasty (ATL) in the treatment of severe limb ischaemia. MATERIALS AND METHODS: Seventy two legs at stage III and IV of Fontaine's classification have been exclusively treated by endoluminal procedures. The success was valued both on the haemodynamic post-operative improvement of the run-off flow and on the clinical statut leading to the conservation at mid-term of a functional limb. Patency and survival rate had been valued by actuarial method. RESULTS: Seventy percent of the limbs were haemodynamically improved. For the global population, a 48% clinical success rate was obtained at 6 months but 30.5% of limbs were loss. Primary patency rate was respectively 79, 71 and 68% at 6, 12 and 24 month. The quality of the run-off arteries has been the most influential factor. CONCLUSION: Endoluminal treatment of chronic limb ischaemia had lead to a clinical improvement in 48% of cases. Multi-stages and distal atherosclerotic disease of this patients limits ATL indications which results depend of run-off quality.     

Percutaneous transluminal angioplasty for severe lower extremity ischaemia

Percutaneous transluminal angioplasty (PTA) was attempted on 70 occasions in 63 consecutive patients presenting with advanced ischaemia. The procedure was technically successful in 64 (91%) with haemodynamic improvement in 39 (56%) and clinical improvement maintained at 6 months in 51 (73%). Follow-up ranged from 6 months to 4 years and life-table analysis showed 60% success at 1 year and 58% success at 2 years. Overall limb salvage was 76%. Complications occurred in 6 (9%) and in one case this lead to amputation. The relationship of a number of associated factors to outcome was assessed. The presence of cardiac disease requiring treatment for failure or angina was a highly significant adverse factor (P less than 0.001). Decreasing age and greater extent of disease were also significant adverse factors (P less than 0.05). Therefore, because of its low morbidity and cost, PTA can be seen as a useful procedure in patients presenting with advanced peripheral vascular disease.     

Percutaneous transluminal angioplasty and primary stenting of the iliac arteries in 288 patients

Purpose: This study reports the initial and late results of percutaneous transluminal angioplasty (PTA) and intravascular stenting for atherosclerotic occlusive disease of the iliac arteries.Methods: The preprocedural and postprocedural clinical records, arteriograms, segmental limb pressure measurements (ankle-brachial [ABI] and thigh-brachial [TBI] indexes), and pulse volume recordings of 288 patients who underwent PTA and primary stenting of the common iliac (354, 69.4%) and external iliac (156, 30.6%) arteries were reviewed. Initial and late clinical, hemodynamic, and angiographic success were assessed by objective criteria. Data on patients who underwent unsuccessful attempts at iliac stent placement are unavailable; results are not reported on an intent-to-treat basis.Results: Clinical follow-up data (mean, 11.9 months) are available for 268 of 288 patients (93.1%) and for 394 of 424 limbs (92.9%). The initial success rates, as determined by TBI, ABI, and clinical limb status, were 90.2%, 87.8%, and 74.6%, respectively. The Kaplan-Meier estimates of angiographic patency (101 arteries) were 96%, 81%, and 73% at 6, 12, and 24 months. Cumulative patency rates were 84%, 76%, and 57% on the basis of TBI, ABI, and clinical limb status at 24 months. Factors associated with initial success included the need for multiple stents (p = 0.0001), a higher degree of initial stenosis (p = 0.0001), lower severity of baseline ischemia (p = 0.007), younger age (p = 0.0015), and the preprocedural patency of the ipsilateral superficial femoral artery (p = 0.002). A higher degree of initial stenosis (p < 0.001) and superficial femoral artery patency (p = 0.004) were also associated with late success.Conclusions: PTA and stenting of the iliac arteries is associated with reasonable angiographic, hemodynamic, and clinical success. The outcome is favorably affected by higher initial severity of stenosis and greater extent of disease, lower severity of baseline ischemia, younger age, and by patency of the ipsilateral superficial femoral artery. (J Vasc Surg 1997;25:829-39.)     

胫腓动脉血管成形术治疗下肢严重缺血35例

目的 评价胫腓动脉经皮血管腔内成形术(percutaneous transluminal angioplasty,PTA)治疗下肢严重缺血的可行性、安全性和有效性.方法 对2004年6月至2007年5月收治的35例胫腓动脉闭塞的下肢严重缺血(critical limb ischemia,CLI)患者应用PTA治疗.评价的主要参数为:胫腓动脉PTA技术成功率、通畅率、救肢率和并发症.结果 胫腓动脉PTA的技术成功率为83%,平均随访11.5个月,通畅率为57%,救肢率82%.胫腓动脉平均扩张长度9.5 cm(4.5～14 cm),19例患者同时行髂或股胭动脉PTA或支架术.有3例并发症发生,其中1例动脉痉挛和血栓形成,经溶柃、解痉等治疗缓解;2例动脉穿孔,未有严重后果.结论 PTA治疗CLI合并胫腓动脉闭塞具有较高技术成功率和救肢率,较少发生严重并发症,是一种安全、有效可供选择的治疗方法.     

Percutaneous transluminal angioplasty for lower limb ischaemia

Forty successful percutaneous transluminal angioplasties (PTA) were performed in the iliac and femoropopliteal segments of 33 patients with lower limb ischaemia. There was immediate symptomatic relief in 37 limbs (92 per cent) although 7 relapsed and 5 patients required reconstructive arterial surgery within a month of PTA. Objective testing showed that the longer term relapse rate (median follow-up 12 months) was low (10 per cent). Despite a significant incidence of early complications and relapse, PTA provided a good long term result in the majority of patients treated.     

Complications after percutaneous transluminal angioplasty in the iliac, femoral, and popliteal arteries

During a 5-year period percutaneous transluminal angioplasty (PTA) was attempted in 134 iliac, femoral, and popliteal arteries in 127 patients. Complications were systematically registered and classified as major, minor, and radiologic. Seventeen major complications (12.7%), including three deaths, occurred, as well as five minor (3.7%) and 13 radiologic complications (9.7%). The last group showed no clinical symptoms. The frequency of complications in our series is high compared with that found in a survey of 13 studies with 2043 patients. The most marked discrepancy was our high frequency of septic symptoms. A mortality rate of 2.2% was also higher in our series, but we have consequently registered the 30-day mortality rate to make comparisons with surgical series relevant. Radiologic alterations are usually not reported in other series probably because they are regarded as a part of the method, but we consider these alterations as potentially dangerous and important to report because they can result in clinically relevant complications. Because of the complications PTA should only be performed in centers in which complications can be optimally treated.     

Percutaneous transluminal angioplasty of subclavian arteries]

12 cases of subclavian arterial stenosis or obstruction were treated with percutaneous transluminal angioplasty (PTA). Atherosclerosis was considered as the cause of the arterial lesion in 7 cases. In 6 of them the lesion was located near the orifice of the subclavian artery. The lesion was 10.8 +/- 5.4 mm in length and 1.67 +/- 0.8 mm in diameter. After PTA the lumen was 6.58 +/- 1.11 mm in diameter. The clinical result was satisfactory. Arteries was found in 5 cases. Most of them had long segment obstructed lesion (46 +/- 36.6 mm in length, and 0.5 +/- 0.5 mm in diameter). The result of PTA was not satisfactory. The technique of PTA has been discussed.     

Percutaneous transluminal angioplasty of infrarenal arteries in intermittent claudication

Percutaneous transluminal angioplasty was performed on 55 iliac and 31 femoropopliteal arteries in 71 patients with intermittent claudication (23 women, 48 men). The two-year patency rate was 80% after iliac and 41% after femoropopliteal angioplasty. In 17 femoropopliteal cases with lesions greater than or equal to 5 cm the 2-year patency rate was only 32%, but the corresponding figure for shorter lesions was 53%. Complicating haematoma appeared in 10% of the cases and the arterial state deteriorated in one patient. There was no distal embolization. Percutaneous transluminal angioplasty in intermittent claudication is indicated for all cases of occlusion or stenosis of the iliac artery and for occlusion or stenosis shorter than 5 cm of the superficial femoral or the popliteal artery.     

Laser-assisted transluminal angioplasty of the superficial femoral and popliteal arteries

During an initial 1-year experience with percutaneous laser-assisted balloon angioplasty at the Vancouver General Hospital, 9 of 61 patients considered suitable for intervention because of arterial occlusive disease were selected for laser treatment. The neodymium-YAG laser with a contact sapphire tip was chosen because the probes and tips are reusable, thereby reducing the cost per patient. The patients had either severe limiting claudication or pain at rest, involving the superficial femoral or popliteal artery. One of the patients had lesions in both legs, making a total of 10 lesions. In 8 of the 10 lesions, treatment initially was successful. In the other two instances, the laser perforated the arterial wall, but the patients suffered no ill effects; repair by bypass surgery was uncomplicated. Another patient had distal thrombosis at the time of angioplasty of the popliteal artery; this responded to fibrinolytic therapy and subsequent balloon angioplasty of the peroneal artery. The initial 80% success rate was reasonable, considering that all these patients would otherwise have undergone bypass surgery. One patient had recurrent stenosis 5 months after the procedure. The other seven had good results with relief of symptoms. However, follow-up has been short (mean 4.9 months), the longest being only 11 months.     

Percutaneous transluminal angioplasty and stenting for iliac artery occlusive disease.

Atherosclerotic iliac artery stenoses respond well to simple balloon angioplasty and have the best results of all of the peripheral vessels. Nonetheless, initial technical failures occur in as many as 20% of patients, most of which can be salvaged with intravascular stenting, as can many of the potential complications; however, even though the initial technical success rates for stenting approach 100%, stenotic recurrences within stents are not infrequent. Whether promising new concepts, such as brachytherapy, gene therapy, and endoluminal grafting, will have a durable impact on the results of iliac angioplasty is yet to be seen. Meanwhile, the excellent results of endoluminal treatment of patients with iliac artery occlusive disease, combined with the relatively low risk for complications compared with surgical revascularization, ensure an enduring role for this modality of treatment and a diminution in the fraction of patients requiring surgery to correct their iliac artery occlusive disease.     

Percutaneous transluminal angioplasty for critical limb ischaemia in octogenarians and nonagenarians.

OBJECTIVE: To determine the early and late outcome of percutaneous transluminal angioplasty (PTA) for critical limb ischaemia (CLI) in patients aged 80 years and over. METHODS: Retrospective case note review of all patients aged 80 years and over who underwent attempted PTA for CLI between 1st January 1999 and 31st December 2000. Minimum follow-up was 12 months with a maximum of 42 months. RESULTS: One hundred and twenty-eight PTAs were attempted in 113 severely ischaemic limbs of 98 patients (36 men and 62 women of median age 84, range 80-97, years). Seventy patients had significant co-morbidity. The indication for revascularisation was rest pain in 47 procedures, ulceration in 66 and digital gangrene in 15. The anatomical segments involved were iliac (n=19), superficial femoral (n=92), popliteal (n=91) and infrapopliteal (n=72). The technical success rate was 108 of 128 (84%) procedures. Early technical complications occurred in 24 (19%) procedures: four major, 20 minor. The 30-day operative mortality rate was six of 128 (5%). The median (range) in-hospital stay was two (1-72) days. Early or delayed surgical revascularisation was required in 11 limbs and there were six major limb amputations during the study period. The 24-month patient survival rate was 59%. The 24-month primary and secondary symptomatic patency and secondary limb salvage rates were 52, 69 and 95%, respectively. DISCUSSION: PTA is safe, requires a short hospital stay, and is clinically effective in the majority of very elderly patients with CLI. Although minimally invasive, the relatively high peri-procedural mortality rate and low 24-month survival rate reflect the high co-morbidity of this group of patients.     

Percutaneous transluminal balloon angioplasty of the iliac artery for contralateral ischemia

The cases of three patients with lower extremity ischemia from ipsilateral iliac artery occlusion and contralateral iliac artery stenosis are presented. Planned treatment was percutaneous transluminal angioplasty (PTA) of the contralateral iliac artery, rendering it an adequate donor vessel for subsequent femorofemoral bypass. Because of adequate collateral vessels across the pelvis, cross-femoral bypass was unnecessary following PTA. Current technology allows simultaneous intraoperative PTA and femorofemoral bypass. We do not recommend this on the basis of our experience.     

Percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty (PTA) was done in a 58-year-old man with hypertension due to a left-sided renal artery stenosis. Hypertension was cured dramatically and plasma renin activity was within the normal range after the operation. This non-traumatic procedure seems to be excellent and recommendable as a first treatment of renovascular hypertension.     

Percutaneous transluminal angioplasty of bilateral vertebral arteries: case report

A 58-year-old female suffered frequent attacks of unconsciousness due to vertebrobasilar insufficiency. She had a slight left hemiparesis, dysarthria, gait disturbance, and decreased vibration sense. Angiography revealed remarkable stenoses of the bilateral vertebral artery origin with inadequate collateral flow from the anterior circulation. Percutaneous transluminal angioplasty (PTA) was performed on the more severely narrowed left vertebral artery through transfemoral approach. This was followed by PTA on the right one through transbrachial approach after an interval of 3 weeks. The procedure cleared off the signs and symptoms; neuroradiological studies including angiography and Xe-CT scan confirmed the improvement. PTA has been performed on stenotic lesions at the origin of the vertebral artery and the common carotid artery with more safety than on stenotic lesions of the other cerebral arteries, because of the smooth luminal non-ulcerated lesions of the former. In spite of the possibility of restenosis after PTA, in selected cases, PTA leads to good results, less complications and shorter stay in hospital. These factors are of major benefit to the patients. In the future, PTA may be an alternative method for treating arterial stenotic lesions in the field of neurosurgery.     

Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries

BACKGROUND: To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication. METHODS: From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion. RESULTS: There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II). CONCLUSIONS: Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.     

Percutaneous transluminal renal angioplasty

Summary Percutaneous transluminal renal angioplasty (PTRA) is a simple, efficient procedure with a low risk/benefit ratio when carried out by experienced interventional radiologists. The role of radiology in the diagnosis and treatment of renovascular hypertension (RVH) is discussed, with special attention to technique. PTRA and surgical results are dependent on the etiology and location of renal artery stenosis (RAS). At New York Hospital-Cornell Medical Center, PTRA is the procedure of choice in fibromuscular dysplasia (FMD), unilateral non-ostial atheroma, arteritis, renal transplantation, and pediatrics. The choice between surgery and PTRA in patients with bilateral and ostial atherosclerotic disease and/or azotemia depends on the surgical risk category of the patient. At our institution, coronary and cerebrovascular disease do not preclude PTRA.