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.     

Complications in percutaneous transluminal angioplasty: relationships with patient age.

Five hundred consecutive attempted lower limb angioplasties for ischaemic disease (370 patients, mean age 65.6 years, range 33-91 years) were reviewed. Significant complications occurred in 44 cases (8.8%). Nine patients (1.8%) underwent emergency surgery related to a complication. A further 12 patients (2.4%) underwent elective surgery related to a complication. In addition, four patients died within 30 days of the procedure; one following surgery performed because of a complication of angioplasty, one following a myocardial infarction, one following severe bleeding associated with subsequent thrombolytic therapy and one during emergency surgery related to a complication of angioplasty. A correlation was found between complication rate and age. This relationship was independent of the approach to, the position of, and the severity of the treated lesion. Elderly patients are at increased risk of complication in lower limb angioplasty.     

Outpatient transluminal angioplasty

The treatment of 81 consecutive patients with transluminal angioplasty on an outpatient basis did not result in increased morbidity or mortality or delayed complications. The patients were treated in the emergency department observation area for four hours after angioplasty and were then allowed to slowly resume normal activities over the next 48 hours. The authors conclude that outpatient angioplasty is safe in a controlled setting and is cost effective since hospitalization is not required.     

Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty, first performed in man in 1977, has been used increasingly in selected patients with angina pectoris due to coronary atherosclerosis. Patients with single-vessel coronary artery disease in whom the stenosis is relatively proximal, noncalcified, discrete, and tapered rather than eccentric are the best candidates for the procedure. Objective evidence of coronary insufficiency documented by scintigraphy or exercise testing allows objective follow-up. Patients must be candidates for coronary artery bypass graft surgery since a complication might require immediate operation. Clinical experience indicates that 60%-85% of patients chosen for coronary angioplasty can have their coronary stenoses successfully dilated. Symptomatic improvement occurs in almost 90% of successful dilatations. Follow-up studies have shown persistent vessel patency for more than 1 year. From 3% to 8% of patients have needed urgent coronary artery bypass graft surgery because of coronary insufficiency developing at the time of angioplasty. Mortality has been less than 1%. The initial favorable experience with coronary angioplasty indicates that it should continue to be evaluated. The limits of patient selection for the procedure and long-term results require further compilation of data.     

Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) has revolutionized the treatment of patients with coronary disease. As many as 25 per cent of those requiring myocardial revascularization can now undergo PTCA instead of bypass surgery. This article reviews PTCA techniques, clinical results, case selection, complications, recent advances in equipment design, restenosis rate, use in acute myocardial infarction, and PTCA of coronary bypass grafts.     

Percutaneous transluminal renal angioplasty

One to 2 percent of the 25,000,000 hypertensive patients in the United States have renovascular hypertension. Until recently, the treatment of choice for a patient with an ischemic, renin-producing kidney that caused hypertension involved a major abdominal operation. Percutaneous catheter techniques are now available that permit correction of a renal artery stenosis under fluoroscopic guidance. This percutaneous transluminal angioplasty procedure has received much attention, but to date no long-term follow-up studies are available. Because of the limited life-expectancy of patients with a generalized arteriosclerotic process and the relatively high risk of operative procedures in this group of patients, it would seem appropriate to consider percutaneous transluminal renal angioplasty as an alternative method in the management of the patient with renovascular hypertension.     

Results of percutaneous transluminal angioplasty

Percutaneous transluminal angioplasty (Dotter technique) was used in 2,942 cases of iliofemoral atheromatous disease. Results varied with the characteristics of the obstructing lesion (length and location) and the clinical stage of ischemia (claudication, rest pain, gangrene). Based on the foregoing, angioplasty is done either as the preferred primary treatment or for the relief of clinically advanced disease in patients unsuitable for high risk surgery. Success is favored by the use of aggregation inhibitors and single-use Teflon or balloon catheters; complications are few.     

Percutaneous transluminal angioplasty following endarterectomy

Recurrent occlusive disease was found by noninvasive methods and confirmed arteriographically in 7 patients who had undergone endarterectomy for stenosis of one [5] or both iliac arteries [1] or the subclavian artery [1]. Three patients with iliac artery stenosis had percutaneous transluminal angioplasty (PTA) 1 to 5 years after endarterectomy. One patient with stenosis of the external iliac artery had PTA 4 years after endarterectomy, and dilatation was repeated 7 months later because of recurrence. One patient had 2 endarterectomies and 2 PTAs within 8 years for stenosis of the right common iliac artery. One patient had recanalization of the left common iliac artery 6 years after endarterectomy with low-dose streptokinase followed by PTA. Another patient underwent endarterectomy of the left subclavian artery 3 months after PTA and required further dilatation at 5 and 10 months because of recurrence. The authors conclude that endarterectomy does not preclude PTA (or vice versa) in patients with recurrent arterial occlusive disease.     

Percutaneous transluminal laser angioplasty]

Percutaneous transluminal laser angioplasty (PTLA) has been carried out on 63 peripheral arterial occlusive lesions in 43 patients. Most patients complained of intermittent claudication. The sites of lesions are the iliac artery (28 lesions or 44.4%), the femoropopliteal artery (30 lesions or 47.6%), and the below knee artery (5 lesions or 8.0%). There are 54 lesions (85.7%) that showed over 70% stenosis, with 19 of them complete occlusions (30.2%). Out of 63 lesions, 16 lesions or 25.4% had occlusions of over 10 cm. A Nd:YAG laser (1.06 microns, continuous wave) was used for the vaporization of atheromatous plaque and old thrombus. The laser was irradiated by increments of 1 to 2 seconds at 80W using the non-contact method, at 10-25W using the contact method with a ceramic tip and at 10-15W with a bare laser fiber. Balloon dilatation was then utilized. The initial success rate was 85.7%. The 5 year cumulative patency rate after PTLA is 88.4% in total cases, 88.7% in the iliac artery, 86.1% in the femoropopliteal artery, and 100% in the below knee artery. The 5 year cumulative patency rate for stenosis of the iliac artery is 91.0%, and it is 92% for stenosis of the femoropopliteal artery, and 81% for occlusion of the femoropopliteal artery. PTLA seems to have improved the cumulative patency rate when compared with that of conventional PTA.     

Percutaneous transluminal angioplasty of crural arteries

The authors dilated 103 stenosed crural arteries in 71 patients. Primary success was defined as traversing and reducing the lesion to a residual stenosis of less than 30%. This was achieved in 96% of cases. Complications included one vessel rupture and one occluding intimal flap, which were treated by the vascular surgeon with bypass and venous patch, respectively. One hematoma at the puncture site was treated surgically because of its size. With modern materials such as steerable guide wires and low-profile balloon catheters, dilation of crural arteries has become safe. Until now, the indications for percutaneous transluminal angioplasty (PTA) of crural arteries have been limited to Fontaine stages III and IV disease. The authors believe that the indications for PTA in Fontaine stage IIb disease are justified, especially if intervention improves outflow after a more proximal recanalizing procedure is performed.     

Percutaneous transluminal angioplasty of nonatherosclerotic lesions

Percutaneous transluminal angioplasty (PTA) was attempted on 16 nonatherosclerotic lesions in 14 patients. Dilatation was initially successful in 4/4 cases with renal artery stenosis due to fibromuscular dysplasia (three) and Takayasu arteritis (one); all patients became normotensive and remain normotensive on no antihypertensive medications, at up to 12 months follow-up. PTA was technically successful in 4/5 transplant renal artery stenosis; these four patients remain normotensive or almost normotensive on no or markedly reduced antihypertensive medications, at up to 14 months followup. Initial success was obtained in 3/3 lesions involving vascular grafts; in one, the patient became and remained asymptomatic for the remaining 5 months he lived; in another, occlusion of the dilated segment and the graft occurred 8 months after PTA; and in the third, symptoms and signs of the limb ischemia returned within 24 hr of PTA. PTA was initially successful in a patient with recurrent celiac artery stenosis after surgery for median arcuate ligament syndrome; she has remained free of symptoms for 18 months. In a patient with three radiation-induced stenoses, PTA was initially successful; this patient is asymptomatic at 20 months follow-up. The medial type of fibromuscular dysplasia dilates most easily, suggesting a concentric stretching and some shearing of the fibrous tissue, which then heals in its dilated state. Intimal fibroplasia may be eccentric, and concentric stretching during dilatation may not be possible, leading to less satisfactory results. Radiation-induced stenosis involves periarterial fibrosis and arterial wall thickening, and the results in PTA of many of these lesions may be less satisfactory than reported here. The responsiveness of graft stenoses will vary with the cause; anastomotic stenoses will probably dilate easily, for they involve either concentric intimal proliferation, or a small degree of periarterial fibrosis; graft stenoses surrounded by dense fibrous tissue may respond initially to PTA, but the long-term results will probably be poor due to recurrent graft constriction.