Cryoplasty for the Treatment of Femoropopliteal Arterial Disease: Will Freezing Solve the Problem of Cold Feet?

Current state of endovascular treatment of femoro-popliteal artery disease

Considerable advances have been made over the last decade in percutaneous technology for the treatment of atherosclerotic diseases in the femoro-popliteal arteries. While treatment strategies are well defined in the iliac segment, where angioplasty and stenting perform well in appropriately selected lesions, the search for a durable transcatheter therapy for femoro-popliteal lesions continues. Whereas balloon angioplasty (PTA) is the accepted therapy for short lesions, long diffuse lesions are still recommended for surgical treatment. However, attractive new technologies ranging from transcatheter plaque excision to laser ablation, rotational atherectomy, cryoplasty, brachytherapy, and placement of drug-eluting stents to simple angioplasty with drug-coated balloons may have the potential to replace femoro-popliteal bypass surgery as a treatment of choice for complex lesions. This article reviews the status of percutaneous endovascular techniques for the treatment of femoro-popliteal artery occlusive disease.

Early endothelial and haematological response to cryoplasty compared with balloon angioplasty of the superficial femoral artery – a pilot study

The purpose of the present study was to assess the course of adhesion molecules (intercellular adhesion molecule (ICAM), vascular cell adhesion molecule (VCAM), e-selectin, p-selectin and monocyte chemoatlractant protein 1 (MCP-1)), growth factors (transforming growth factor beta (TGFbeta) and basic fibroblast growth factor (bFGF)) and the cytokine tumour necrosis factor alpha (TNFalpha) after both angioplasty and cryoplasty. Recently cryoplasty has been suggested as a new method to oppose neointimal hyperplasia resulting in restenosis formation. While in vitro models have shown that the application of cryothermal energy to the endothelium during angioplasty leads to apoptosis induction and reduced proliferation rates, no human in vivo proof for an inhibition of neointimal hyperplasia exists. For restenosis initiation adhesion molecules, growth factors and cytokines play an important role. One possibility to investigate the endothelial response to angioplasty is the measurement of the soluble forms of adhesion molecules, growth factors and cytokines that are released into the circulation after denuding the vessel wall. In the present study we assessed the distribution pattern of the soluble forms of e-selectin, p-selectin, ICAM, VCAM, MCP-1, TGFbeta, bFGF and TNFalpha after angiography, angioplasty and cryoplasty of the femoropopliteal artery in the early course of 4 weeks in 29 patients with peripheral arterial occlusive disease. During the 4 weeks after intervention levels of e-selectin, ICAM, VCAM and MCP-1 increased after both angioplasty and cryoplasty. The course of the screened biomarkers was similar between angioplasty and cryoplasty. P-selectin and TGFbeta both decreased after cryoplasty, but not significantly. The present results show that the release of adhesion molecules, growth factors and cytokines is similar between balloon angioplasty and cryoplasty.

Treatment of Ureterointestinal Anastomotic Strictures by Diathermal or Cryoplastic Dilatation

BACKGROUND

Ureterointestinal anastomotic strictures (UAS) complicate 10-15% of surgeries for urinary diversion and are the main cause of deterioration in renal function. Treatments are surgical revision, management with autostatic stent, balloon dilatation, endoscopic incision, and percutaneous transrenal diathermy (Acucise). A new option is cryoplastic dilatation (Polar-Cath).

PURPOSE

To assess the feasibility, complications, and preliminary results of UAS treatment using the Acucise and Polar-Cath systems.

METHODS

Nineteen UAS, diagnosed by ultrasonography or computed tomography and sequential renal scintigraphy, occurred in 15 cancer patients after radical cystectomy and urinary diversion. Fifteen were managed with balloon diathermy and 4 by balloon cryoplasty in a three-stage procedure--percutaneous nephrostomy, diathermal or cryoplastic dilatation, and transnephrostomic control with nephrostomy removal--each separated by 15 days. All patients gave written informed consent.

RESULTS

Dilatations were successful in all cases. The procedure is simple and rapid (about 45 min) under fluoroscopic control and sedation. Procedural complications occurred in 1 (5%) patient with UAS after Wallace II uretero-ileocutaneostomy: a common iliac artery lesion was induced by diathermal dilatation, evident subsequently, and required surgical repair. Patency with balloon diathermy was good, with two restenoses developing over 12 months (range 1-22) of follow-up. With balloon cryoplastic dilatation, one restenosis developed in the short term; follow-up is too brief to assess the long-term efficacy.

CONCLUSION

Our short-term results with diathermal and cryoplastic dilatation to resolve UAS are good. If supported by longer follow-up, the techniques may be considered as first-choice approaches to UAS. Surgery should be reserved for cases in which this minimally invasive technique fails.