Complications in percutaneous transluminal angioplasty: relationships with patient age

How to define the hemodynamic significance of an equivocal iliofemoral artery stenosis: Review of literature and outcomes of an international questionnaire

Purpose

The goal of the study was to review current literature regarding the diagnosis of equivocal (50–70%) iliofemoral artery stenosis and compare these findings with the daily practice of an international panel of endovascular experts.

Methods

The Medline Database was searched for relevant publications, and an electronic survey was sent to experts in the field covering the following topics: definition of an equivocal iliofemoral artery stenosis, angiographic visualization and investigation protocols of an equivocal stenosis, intra-arterial pressure measurements, and definition of hemodynamic significance of an equivocal iliofemoral artery stenosis using a physiologic measure.

Results

Of the 37 invited endovascular experts, 21 (53.8%) agreed to participate in the survey. Analysis of existing literature shows that the level of evidence for diagnosing equivocal iliofemoral artery stenosis is mediocre and is not being implemented by experts in the field.

Conclusion

Studies have shown that a stenosis of between 50% and 70% iliofemoral lumen diameter reduction shows a wide range of trans-stenotic pressure gradients. Equivocal iliofemoral artery stenosis can best be identified using three-dimensional quantitative vascular analysis software. Although evidence for a clear hemodynamic cutoff point is weak, performing trans-lesion intra-arterial pressure measurements at rest and during maximal hyperemia is preferred. Diagnosing iliofemoral artery stenosis solely on lumen diameter reduction is inadequate.

Effect of a one-session versus two-session procedure on different parameters of interventional therapy for peripheral arterial occlusive disease: results of a retrospective cohort study

PURPOSE

To compare the effects of a one-session procedure (ie, diagnostic angiography immediately followed by intervention) versus a two-session procedure (ie, diagnostic angiography and intervention in two separate sessions) on interventional therapy in patients with peripheral arterial occlusive disease (PAOD).

MATERIALS AND METHODS

Interventional therapy was performed immediately after diagnostic angiography in one session in 228 patients (group 1) and in a chronologically separate, later session in another 43 patients (group 2). The retrospectively captured parameters were Fontaine stage, TransAtlantic InterSociety Consensus II criteria, angiographic severity, type, technical success and complication rates, examination times, volume of contrast media, radiation exposure, and fluoroscopy time for intervention.

RESULTS

There were no between-group differences in clinical and interventional parameters. In group 1 there were 340 interventions performed, and there were 61 in group 2 with an interval before intervention of 1-55 days. The groups showed comparable success rates (92.6% vs 91.8%; P = .79) and complication rates (5.7% vs 4.65%; P = 1.0). The examination times were similar at 82.6 minutes +/- 40.5 and 91.3 minutes +/- 69.9, respectively (P = .92). Volume of contrast media (301.7 mL +/- 81.3 vs 459.2 mL +/- 123.7) and radiation exposure (140.5 Gy/cm(2) +/- 152.1 vs 304.7 Gy/cm(2) +/- 217.4) were significantly lower in group 1 (P < .001 each). Fluoroscopy times trended lower in group 1.

CONCLUSIONS

In patients with PAOD, interventional therapy of iliac and femoropopliteal artery lesions performed in the same session as diagnostic angiography yields technical success and complication rates comparable to those seen with a two-session procedure, but is associated with significantly less contrast media use and radiation exposure.

Infrainguinal occlusive disease: endovascular intervention is the first line therapy

The preferred treatment of infrainguinal occlusive disease at many centers has undergone a paradigm shift from open bypass to endovascular intervention as the first-line therapeutic modality. Our own experience supports a percutaneous first approach. Though skeptics initially cited lower primary patency rates for angioplasty when compared with bypass, more recent studies have shown favorable secondary patencies nearly challenging that of bypass. The need for repeat endovascular intervention to achieve a higher secondary patency is not a major deterring factor because most procedures are associated with a short hospital stay and a relatively low rate of complication. The risk is low and this complex group of patients can tolerate minimally invasive reinterventions well. The longevity of this patient population is generally short, and consequently less durable outcomes may be acceptable. Patients do require close follow-up with early treatment of restenosis. However, there appears to be a decreased cost of intervention when compared with surgery. Furthermore, the functional outcomes and quality of life appear more optimal with angioplasty. The concern that angioplasty may preclude future surgical intervention by damaging the distal bypass target has not borne true. It is unusual for a percutaneous therapy to eliminate the possibility of a bypass should the endovascular approach not be successful. Finally, advances in techniques and devices may herald improved outcomes because percutaneous therapy in the periphery is still in the early stages of its maturation. Thus, endovascular intervention has become an established, as well as a developed method for treating peripheral arterial occlusive disease and should be considered the first-line therapeutic modality for patients with.lower extremity vascular disease.

Complications in Peripheral Vascular Interventions: Emerging Role of Direct Thrombin Inhibitors

Unfractionated heparin is associated with a high rate of bleeding and thrombotic complications during peripheral vascular interventions (PVIs). Newer anticoagulants such as direct thrombin inhibitors might offer significant advantages over heparin. Early data with bivalirudin in the peripheral circulation are promising. Bivalirudin appears safe and effective when used during PVIs. Data with the use of other direct thrombin inhibitors (hirudin, r-hirudin, argatroban, and melagatran) in peripheral interventions are still lacking. Among these, argatroban and melagatran have pharmacologic properties that might offer some advantages in PVI, but further studies are needed to demonstrate their safety and effectiveness.

Techniques for the endovascular management of complications following lower limb percutaneous transluminal angioplasty

OBJECTIVES

to determine the incidence of early complications following percutaneous transluminal angioplasty and to describe their management and outcome.

MATERIALS

five hundred and fifty consecutive patients undergoing angioplasty of 648 limbs, containing 1053 anatomical segments during a two year period were reviewed retrospectively.

RESULTS

early complications affected 109 segments (10%) in 92 limbs (14%) of 84 patients (15%). Of the 109 segments affected by early complications, 106 (97%) were managed by endovascular techniques with surgery being required on only three (3%) occasions. There were no deaths attributable to angioplasty.

CONCLUSIONS

although early complications occur in 14% of limbs undergoing percutaneous transfemoral angioplasty, the majority (97%) can be managed by endovascular techniques.

[Immediate results and 2-year follow-up of percutaneous transluminal angioplasty in intermittent claudication in patients over 70 years of age]

PURPOSE

This retrospective study was aimed at assessing immediate and mid-term results of percutaneous transluminal angioplasty for intermittent claudication in patients over 70 years of age, and the overall morbidity and mortality during follow-up.

METHODS

Fifty-one percutaneous transluminal angioplasties were performed between 1993 and 1997 in 30 men and eight women (mean age: 78 +/- 5.2; range 71-91) for intermittent claudication (walking distance < 250 m).

RESULTS

Angioplasties were supra-inguinal in 24 cases (47%) and infra-inguinal in 27 cases (53%). Clinical success (walking distance > 500 m) was obtained in 92% of the patients. Significant complications (5.9%) were inguinal hematoma requiring subsequent surgery in one patient and common femoral false aneurysms in two patients. Mean duration of hospitalization was 3 days and a half. After a mean follow-up of 25 months (range: 4-51 months), improvement in the walking distance was still present in 31 patients (82%). The condition of seven (18%) patients did not improve. No patient presented with critical ischemia. As well, no patient underwent surgical revascularization or amputation. However, the condition of eight (21%) patients required subsequent percutaneous transluminal angioplasty. Four (10.5%) patients died. Following percutaneous transluminal angioplasty, six (18%) patients presented with a major non-fatal clinical event. All the patients lived at home.

CONCLUSION

Percutaneous transluminal angioplasty has little immediate risk when lesions are accessible and leads to positive mid-term clinical results in the treatment of intermittent claudication in patients over 70 years of age.

Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients

PURPOSE

To evaluate complications and their predictors in percutaneous transluminal angioplasty (PTA) of lower-limb arteries.

METHODS

Complications in 410 angioplasty procedures in 295 consecutive patients (192 claudicants and 103 suffering from chronic critical ischemia) were prospectively analyzed.

RESULTS

The total complication rate was 10.5% (43/410). There were 21 major complications (5%), eight of which required surgical treatment, including four hematomas, two arteriovenous fistulae, and two pseudoaneurysms at the puncture site, two retroperitoneal hematomas, and 11 thrombotic/thromboembolic complications. There were significantly more complications with treatment of occlusions compared with stenoses (18% vs 7%, p = 0.002). Women had significantly more bleeding complications than men (15% vs 6%, p = 0.032). The 30-day mortality rate in patients with critical ischemia was 10%.

CONCLUSION

In lower-limb PTA a few target lesion- and patient-related determinants of complications could be identified. In patients with critical ischemia, the 30-day mortality was rather high and mainly due to associated coronary and cerebrovascular diseases.

Cumulative risk of bypass, amputation or death following percutaneous transluminal angioplasty

OBJECTIVE

To define cumulative risk of reconstruction, amputation or death following percutaneous transluminal angioplasty (PTA).

DESIGN

Non-randomised observational study.

PATIENTS AND METHODS

Two hundred and thirty-four PTAs in 212 patients. Minimum follow-up 6 months. Examination of data collected prospectively on manual card index. Examination of radiology and theatre ledgers over 2.5-year period. District Information System (Dis Data). Life-table analysis.

RESULTS

The cumulative risks of reconstruction at 12 months were 14.9% and 6.7%, respectively, following angioplasties below and above the inguinal ligament. Major and minor amputations were more common if the original lesions were below the inguinal ligament (relative risk (RR) 3.32, confidence interval (CI) CI 0.42-26.26 and RR 4.24, CI 0.055-32.9, respectively). They were also more likely in diabetic compared with non-diabetic patients (RR 9.95, CI 2.85-34.47 and RR 3.66, CI 1.28-10.44, respectively). No patient who presented with claudication underwent amputation. Death was more common in patients originally presenting with rest pain or gangrene than claudication (RR 3.94, CI 1.51-10.31).

CONCLUSION

This study confirms the poor outlook of diabetic patients with peripheral vascular disease or those presenting with rest pain, ulceration or gangrene. Percutaneous transluminal angioplasty was associated with approximately 80% limb salvage rate in those patients during the duration of the study.

Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial

OBJECTIVES

To compare percutaneous transluminal angioplasty (PTA) against exercise training in the treatment of stable claudication.

DESIGN

Prospective, randomised trial.

MATERIALS

Fifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review.

OUTCOME MEASURES

Ankle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise.

RESULTS

Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation.

CONCLUSIONS

Exercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.