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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3591_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Preface
- •Acknowledgments
- •Contents
- •About the Editor
- •1.6 Acute Gastrointestinal Bleeding
- •1.7 Transjugular Intrahepatic Portosystemic Shunt
- •1.8 Conclusion
- •References
- •2.1 Introduction
- •2.2 History-Taking
- •2.4 Pre-procedure Imaging
- •2.5 Pre-procedure Investigations
- •2.8 Informed Consent
- •2.10 Part Preparation
- •2.11 Antibiotic Prophylaxis
- •References
- •3.1 Introduction
- •3.2 Ultrasonography
- •3.2.1 Advantages
- •1.1 Introduction
- •1.2 Early Beginnings
- •1.3 Catheter-Directed Thrombolysis
- •1.4 Stents
- •1.5 Coronary Angiography
- •3.2.3 Limitations
- •3.3 Fluoroscopy
- •3.3.1 Indications
- •3.3.2 Interventional Fluoroscopy
- •3.3.2.1 Digital Subtraction Angiography
- •3.4 Computed Tomography
- •3.4.2 Indications
- •3.4.3 Limitations
- •3.5 Magnetic Resonance Imaging
- •3.5.3 Limitations
- •3.6.3 Remove Anti-scatter Grid
- •3.6.4 Pulsed Fluoroscopy
- •3.6.5 Checklist
- •3.9 Conclusion
- •References
- •4.1 Introduction
- •4.2 Pharmaceutical Agents
- •4.2.1 Contrast Agents
- •4.2.2 Iodinated Contrast Media (ICM)
- •Pathogenesis
- •Risk Factors
- •Diagnosis
- •Risk Threshold
- •4.5 Conclusion
- •References
- •4.3 Carbon Dioxide
- •4.3.1 Indication
- •4.3.2 Contraindications
- •4.3.3 Equipment
- •4.3.4 Preparation
- •4.3.5 Technique
- •4.3.6 Complications
- •4.3.7 Advantages
- •4.3.8 Disadvantages
- •4.4.1 Thrombolytics
- •First-Generation Thrombolytic Agents
- •Second-Generation Thrombolytic Agents
- •Third-Generation Thrombolytic Agents
- •4.4.1.2 Contraindications
- •4.4.2 Anticoagulants
- •4.4.2.1 Unfractionated Heparin (UFH)
- •Mechanism
- •Indications
- •4.4.2.2 Low-Molecular-Weight Heparin (LMWH)
- •Mechanism
- •Indications
- •Special Considerations
- •4.4.2.3 Warfarin
- •Mechanism
- •Indications
- •Special Considerations
- •4.4.3 Antiplatelet Drugs
- •4.4.3.1 Aspirin
- •Mechanism
- •Recommendations
- •4.4.3.2 Clopidogrel
- •Mechanism
- •Recommendations
- •4.4.3.3 Glycoprotein IIb/IIIa Inhibitors (GPI)
- •Mechanism
- •Recommendations
- •4.4.4 Vasodilators
- •4.4.4.1 Nitroglycerine
- •Mechanism
- •Indications
- •4.4.4.2 Verapamil
- •Mechanism
- •Indications
- •Contraindications
- •Complications
- •4.4.5 Vasoconstrictors
- •4.4.5.1 Mechanism
- •4.4.5.3 Indication
- •4.4.6 Prothrombotics
- •4.4.6.1 Mechanism
- •4.4.6.3 Indications
- •4.4.6.5 Special Considerations
- •5.1 Introduction
- •5.2 Pre-procedure Tasks
- •5.2.4 Pre-anesthetic Evaluation
- •5.3 Anesthesia Techniques
- •5.3.1 Local Anesthesia
- •5.4 Pediatric IR Procedures
- •5.5 Anesthesia Considerations
- •5.11 Conclusion
- •References
- •6.1 Introduction
- •6.3 Pre-procedural Workup
- •6.3.1 Prothrombin Time (PT-INR)
- •6.3.3 Viscoelastic Tests
- •6.4.1 Procedure-Related Bleeding Risk
- •6.5.1 Chronic Liver Disease
- •6.5.2 Chronic Kidney Disease
- •6.5.3 Thrombocytopenia
- •6.5.4 Disseminated Intravascular Coagulation (DIC)
- •6.5.5 Malignancy
- •6.6 Bridge Therapy
- •6.7 Deep Vein Thrombosis (DVT)
- •6.8 Atrial Fibrillation (AF)
- •6.9 Coronary Stents
- •6.10 Conclusion
- •References
- •7.1 Introduction
- •7.4 Embolic Agent Selection
- •7.5.1 Gelfoam Embolization
- •7.5.2 Coil Embolization
- •7.5.3 Amplatzer Vascular Plug Embolization
- •7.5.4 Glue Embolization
- •7.6 Clinical Applications
- •7.6.1.1 Endovascular Approach
- •Parent Artery Preservation [16, 17]
- •Stent or Balloon-Assisted Coiling [20, 21]
- •Multi-Layered Flow-Diverting Stents [22]
- •7.6.1.2 Parent Artery Occlusion
- •Sandwich Technique [19–22]
- •7.6.1.3 Percutaneous Approach [16, 17, 24, 25]
- •7.6.2 Tumoral Embolization
- •7.6.3 AVM Embolization
- •7.6.5 Special Scenario
- •7.6.5.1 Provocative Angiography
- •7.6.5.2 Lower GI Bleeding
- •7.6.5.3 Hepatic Artery Aneurysm
- •7.6.5.4 Renal Artery Aneurysm (RAA)
- •7.7 Newer Embolizations
- •7.7.1 Genicular Artery Embolization
- •7.8 Conclusion
- •References
- •8.1 Introduction
- •8.2 Puncture Needles
- •8.3 Guidewires
- •8.4 Sheath System
- •8.5 Catheters
- •8.6 Microcatheters
- •8.7 Embolizing Agents
- •8.7.1 Gelatin Foam
- •8.7.2 Autologous Blood Clot
- •8.7.3 Thrombin
- •8.7.4 Coils
- •8.7.5 Vascular Plugs
- •8.7.6 Particulate Agents
- •8.7.7 Liquid Embolic Agents
- •8.8 Detachable Balloons
- •References
- •9.1 Introduction
- •9.2 Balloons
- •9.2.1 Basics
- •9.2.7 Balloon Ratings
- •9.2.11 Balloon Catheter Design
- •9.2.13 Complications
- •9.2.14 Occlusion Balloons
- •9.2.15 Angioplasty–Pearls
- •9.3 Stents
- •9.3.4 Raw Material Form
- •9.3.5 Fabrication
- •9.3.6 Geometry
- •9.3.7 Additions
- •9.3.8 Drug-Eluting Stents
- •9.3.10.1 Arterial Indications
- •9.3.10.2 Venous Indications
- •9.3.10.3 Non-vascular Indications
- •9.3.11 Uncovered vs. Covered (PTFE) SEMS
- •9.3.12 Stent Grafts
- •References
- •10: Vascular Access
- •10.1 Introduction
- •10.2 Indications
- •10.3 Hardware
- •10.3.1 Intravenous Cannula
- •10.3.2 Puncture Needle
- •10.3.3 Arterial Access Sheath
- •10.4 Local Anesthesia
- •10.6 General Considerations Before Procedure
- •10.7 Arterial Access
- •10.7.2 Arterial Access Sites
- •10.7.2.1 Common Femoral Artery
- •10.7.2.2 High Brachial or Axillary Artery
- •10.7.2.3 Radial Artery
- •10.7.2.4 Pedal Access [3]
- •10.7.2.5 Others
- •10.8 Post-procedure Care
- •10.8.1 Manual Compression
- •10.8.2 Vascular Closure Devices (VCD)
- •10.9 Complications [5–8]
- •10.10 Venous Access
- •10.10.1 Common Femoral Vein
- •10.10.2 Internal Jugular Vein
- •10.10.3 Subclavian Vein Access
- •10.10.4 Upper Extremity Vein Access
- •10.11 Conclusion
- •References
- •11: Neurointerventions Including Aneurysm Interventions
- •11.1 Introduction
- •11.2 Neurovascular Interventions
- •11.3.1 Introduction
- •11.3.3 Clinical Presentation
- •11.3.8 Endovascular Techniques
- •11.3.9 General Technical Guidelines
- •11.3.10 Simple Coiling
- •11.3.11 Balloon-Assisted Coiling
- •11.3.12 Stent-Assisted Coiling
- •11.3.13 Flow Diverter/Braided Stents
- •11.3.14 Stent Graft
- •11.3.15 Parent Artery Occlusion
- •11.3.16 Endosaccular Devices
- •11.4.1 Pathophysiology
- •References
- •12.1 Introduction
- •12.4 Thrombectomy Techniques
- •12.5 Aspiration Technique
- •12.5.1 Stentriever Technique
- •12.6 Combination Technique
- •12.7 Balloon Guide Catheters (BGC)
- •12.8 Special Situations
- •12.8.1 Posterior Circulation Stroke
- •12.8.2 Tandem Occlusions
- •12.8.3 Intracranial Atherosclerotic Disease (ICAD)
- •12.8.4 Medium Vessel Occlusions (MeVO)
- •12.9 Complications
- •12.10 Immediate Post-procedure Care
- •References
- •13.1 Introduction
- •13.2 Brain AVMs
- •13.2.1 Introduction
- •13.2.2 Epidemiology
- •Embolic Agents
- •Embolization Techniques
- •Embolization by Copolymers: Technical Aspects
- •13.3 Intracranial Dural Arterio-Venous Fistulas (DAVFs)
- •13.4 VGAM
- •13.5 Spinal Vascular Malformations
- •13.5.1 Introduction
- •13.5.2 Anatomy
- •13.5.4.3 Spinal Epidural AVMs
- •13.5.4.4 Metameric AVMs
- •References
- •14: Other Neurointerventions
- •14.1 Introduction
- •14.2 Direct CCF
- •14.2.2 Treatment
- •14.3 Epistaxis
- •14.4 Neck Vessel Pathologies
- •14.4.2 Etiopathogenesis
- •14.4.3 Clinical Presentation
- •14.4.4 Management
- •References
- •15.1 Introduction
- •15.4.2 Embolization Agents
- •15.5 Conclusion
- •References
- •16: Carotid Artery Interventions
- •16.1 Introduction
- •16.2.1 Imaging
- •16.2.2.1 Symptomatic Carotid Artery Stenosis
- •16.2.2.2 Asymptomatic Carotid Artery Stenosis
- •16.2.3 Best Medical Therapy
- •16.3 Carotid Artery Stenting
- •16.3.1 Preprocedure
- •16.3.2 Hardware
- •16.3.2.1 Procedure
- •16.5 Complications
- •16.5.1 Early Complications
- •16.5.2 Late Complications
- •16.6 Internal Carotid Artery Stenting
- •16.7 Conclusion
- •References
- •18.1 Introduction
- •18.2 Anatomical Considerations
- •18.3 Aortic Dissection
- •18.3.1 Introduction
- •18.3.2.3 Natural History
- •18.3.2.4 Imaging Options
- •18.3.2.6 Conventional Management Plan
- •18.4 Aortic Aneurysms
- •18.4.1 Overview
- •18.4.4 Thoraco-Abdominal Aortic Aneurysm
- •18.4.5 Abdominal Aortic Aneurysm (AAA)
- •18.4.5.3 Endovascular Intervention
- •18.4.6.1 Epidemiology
- •18.4.6.3 Pathophysiology
- •18.4.7 PAU
- •18.4.7.1 Imaging
- •18.4.7.2 Prognosis
- •18.4.7.3 Management
- •18.4.8 PAU
- •18.5.1 Access Site
- •18.5.2 Procedure
- •18.5.3 Post-Procedure Care
- •18.5.4 Follow-Up Imaging
- •18.6.1 Device-Related Complications
- •18.6.2 Systemic Complications
- •18.7 Endoleaks
- •References
- •19: Vascular Thoracic Interventions
- •19.1 Introduction
- •19.2 Bronchial Artery Embolization (BAE)
- •19.2.1.3 Pre-Procedure Evaluation
- •19.2.2 Bronchoscopy
- •19.2.2.1 Technique
- •19.2.2.2 Post-Procedure Care
- •19.2.2.3 Complications
- •19.3 Pulmonary Artery Pseudoaneurysm (PAPA)/Pulmonary AVM (PAVM) Embolization
- •19.3.1 Pre-Procedure Evaluation
- •19.3.1.2 Technique
- •19.3.2 Post-Procedure Care
- •19.3.3 Complications
- •19.4.1 Pre-Procedure Evaluation
- •19.4.2 Technique
- •19.4.3 Complications
- •19.4.4 Post-Procedure Follow-Up
- •19.5 Thoracic Duct Interventions
- •19.5.1 Pre-Procedure Evaluation
- •19.5.2 Lymphangiography Technique
- •19.5.3 Thoracic Duct Embolization Technique
- •19.5.4 Complications
- •19.5.4.2 Central Lymphatic Access Complications
- •References
- •20.1 Introduction
- •20.2 Pulmonary Embolism
- •20.2.3 Pulmonary Angiography
- •20.2.3.1 Technique
- •20.2.3.2 Post-Procedure Care
- •20.2.3.3 Complications
- •20.2.4.1 Intravenous Thrombolysis
- •20.2.4.2 Catheter-Directed Thrombolysis
- •20.2.4.3 Mechanical Thrombectomy
- •Rheolytic Thrombectomy Devices
- •Aspiration Thrombectomy Devices
- •20.3.1 Clinical Manifestations [16, 17]
- •20.3.3 Radiological Findings
- •20.3.4 Endovascular Management
- •20.3.4.1 Pre-Procedure Evaluation
- •20.3.4.2 Technique
- •20.3.4.3 Post-Procedure Care
- •20.3.4.5 Current Evidence
- •20.4 Pulmonary Artery Aneurysm
- •20.4.1 Endovascular Management
- •20.4.1.1 Technique
- •References
- •21: Hepatic Arterial Interventions
- •21.1 Introduction
- •21.2 Hepatic Arterial Anatomy
- •21.2.1 Normal Celiac Anatomy
- •21.2.2 Normal Hepatic Artery Anatomy
- •21.2.3 Variant Anatomies
- •21.3.1.2 Contraindications
- •21.3.1.3 Patient Selection
- •21.3.1.4 Patient Preparation
- •21.3.1.6 Response Evaluation
- •21.3.1.7 TACE Failure
- •21.3.1.8 TACE Discontinuation
- •21.3.1.9 Complications
- •21.3.2 Transarterial Radioembolization (TARE)
- •21.3.2.2 Contraindications [24]
- •21.3.2.3 Agents Used
- •21.3.2.4 First Visit (Planning)
- •21.3.2.5 Second Visit (Microsphere Injection)
- •21.3.2.6 Complications
- •21.3.3 Transarterial Bland Embolization (TAE)
- •21.3.4 Hepatic Artery Infusion Chemotherapy (HAIC)
- •21.4.1 Neuroendocrine Liver Metastasis (NELM)
- •21.4.2 Other Liver Metastases
- •21.4.3 Intrahepatic Cholangiocarcinoma (IHCC)
- •21.4.4 Benign Liver Tumors
- •21.4.4.1 Hemangiomas
- •21.4.4.2 Focal Nodular Hyperplasia
- •21.4.4.3 Hepatocellular Adenoma
- •21.4.4.4 Polycystic Liver Disease
- •21.8 Hepatic Parenchyma Repopulation
- •References
- •22.1 Introduction
- •22.2 Transjugular Liver Biopsy (TJLB)
- •22.2.1 Patient Preparation
- •22.2.2 Procedure
- •22.2.3 Post-Procedural Care
- •22.2.4 Complications
- •22.3 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- •22.3.3 Pre-Procedural Evaluation [12–14]
- •22.3.4 Technique
- •22.3.5 Post-Procedural Care
- •22.3.6.1 Extrahepatic Portal Vein Puncture [18, 19]
- •22.3.6.2 Hepatic Artery Injury [18–20]
- •22.3.7 Discussion
- •22.4 Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)
- •22.4.1 Indications and Contraindications of BRTO
- •22.4.2 Pre-Procedural Evaluation
- •22.4.3 Requirements
- •22.4.4 Sclerosants
- •22.4.5 Relevant Anatomy
- •22.4.6 Techniques
- •22.4.8 Discussion
- •22.5 Portal Vein Thrombosis (PVT)
- •22.6.2 HV/IVC Stenting
- •22.6.3 Tips/Dips
- •22.6.4 HV/IVC Thrombolysis
- •22.6.5 Discussion
- •22.7 Portal Vein Embolization
- •22.7.5 Pre-Procedural Evaluation
- •22.7.6 Techniques
- •22.7.7 Embolizing Materials
- •22.7.8 Hypertrophy Response
- •22.7.11 Discussion
- •22.8 Transjugular Kidney Biopsy (TJKB)
- •22.8.1 Indications
- •22.8.2 Rationale
- •22.8.3 Pre-Procedural Workup
- •22.8.4 Techniques
- •22.9 IVC Filter
- •22.9.2 Patient Preparation
- •22.9.4 Procedure
- •22.9.5 Complications [98, 102]
- •References
- •23.1 Introduction
- •23.2 Anatomy
- •23.2.1 Arterial Anatomy
- •23.2.2 Venous Anatomy
- •23.3 Arterial Interventions
- •23.3.1 Renovascular Hypertension
- •23.3.2 Atherosclerotic Renal Artery Stenosis
- •23.3.3 Non-atherosclerotic RAS
- •23.3.4 Takayasu Arteritis (TA)
- •23.3.5 Fibromuscular Dysplasia (FMD)
- •23.5.2.1 Preprocedural Evaluation
- •23.5.2.2 Preprocedural Instructions
- •23.5.2.3 Procedure
- •23.5.2.4 Angiography
- •23.5.2.5 Balloon Angioplasty
- •23.5.2.6 Cutting Balloon Angioplasty
- •23.5.2.7 Stenting
- •23.5.2.9 Post-Procedural Care
- •23.5.2.10 Complications
- •23.6.1 Procedure
- •23.7 Renal Artery Aneurysms (RAAs)
- •23.8.1 Etiology
- •23.8.2 Clinical Presentation
- •23.8.3 Endovascular Management
- •23.9.1 Angiomyolipoma
- •23.9.2 Renal Cell Carcinoma (RCC)
- •23.10 Venous Interventions
- •23.10.1 Nutcracker Syndrome (NCS)
- •23.10.1.1 Diagnosis
- •23.10.1.2 Management
- •23.10.1.3 Endovascular Management
- •23.10.1.4 Procedure
- •23.10.1.5 Complications
- •23.10.2 Renal Vein Thrombosis
- •23.10.2.1 Clinical Presentation
- •23.10.2.2 Management
- •23.10.2.4 Procedure
- •References
- •24.1 Introduction
- •24.2 Relevant Anatomy
- •24.3 Mesenteric Ischemia
- •24.3.1 Clinical Features
- •24.3.2 Imaging
- •24.3.3 Treatment
- •24.3.3.2 Intra-Arterial Thrombolysis
- •24.3.3.3 Mechanical Thrombectomy
- •24.4 Gastrointestinal Hemorrhage
- •24.4.1 Clinical Features
- •24.4.2 Endoscopy
- •24.4.3 Imaging
- •24.4.4.2 Complications
- •24.5 Bariatric Embolization
- •24.5.1 Technique
- •References
- •25.1 Introduction
- •25.2 Uterine Artery Embolization (UAE)
- •25.2.1 Indications [1, 2]
- •25.2.2 Contraindications [1, 2]
- •25.2.3 Relevant Vascular Anatomy [2]
- •25.2.4 Preprocedural Evaluation
- •25.2.5 Technique
- •25.2.6 Post-Procedural Care
- •25.2.7 Complications
- •25.2.8 Outcome
- •25.3 Prostatic Artery Embolization (PAE)
- •25.3.1 Rationale Behind PAE
- •25.3.2 Indications [17, 18]
- •25.3.3 Contraindications [18]
- •25.3.4 Preprocedural Evaluation [17]
- •25.3.5 Clinical Assessment
- •25.3.7 Imaging
- •25.3.7.1 Ultrasonography (USG)
- •25.3.7.2 Computed Tomography (CT)
- •25.3.7.3 Magnetic Resonance Imaging (MRI)
- •25.3.9 Relevant Vascular Anatomy
- •25.3.10 Technique
- •25.3.11 Complications
- •25.3.12 Post-Procedural Follow-Up
- •25.3.13 Outcome
- •25.4 Varicocele Embolization
- •25.4.1 Indications [22, 26]
- •25.4.4 Relevant Vascular Anatomy
- •25.4.5 Preprocedural Evaluation [23, 25]
- •25.4.6 Technique
- •25.4.6.2 Venous Access [25, 27, 28]
- •25.4.6.3 Venography [25, 27]
- •25.4.6.4 Embolization [25, 27, 29–31]
- •25.4.7 Post-Procedural Care
- •25.4.8 Complications
- •25.4.9 Outcome
- •25.5 Pelvic Congestion Syndrome
- •25.5.1 Indication [38]
- •25.5.2 Contraindications [38]
- •25.5.3 Preprocedural Evaluation
- •25.5.4 Relevant Vascular Anatomy
- •25.5.5 Technique
- •25.5.6 Post-Procedural Care
- •25.5.7 Complications
- •25.5.8 Outcome
- •25.6 Penile Angiography
- •25.6.1 Penile Vascular Anatomy
- •25.6.2 Technique
- •25.6.3 Complications
- •25.6.4 Outcome
- •References
- •26.2 Peripheral Arterial Disease (PAD)
- •26.2.1 Introduction
- •26.2.5.1 Non-imaging/Functional Modalities
- •26.2.5.2 Imaging Evaluation
- •26.2.6 Management Strategies
- •26.2.6.3 Revascularization Strategies
- •26.3.2 Preprocedural Evaluation
- •26.3.5 Complications
- •26.3.6 Stenting
- •26.3.7 Post-Procedure
- •26.5 Recent Advances
- •26.5.2 Drug-Eluting Technology
- •26.5.3 Bioresorbable Stents
- •26.5.6 Pedal Arch Revascularization
- •26.5.7 Percutaneous Deep Vein Arterialization (DVA)
- •26.6 Acute Limb Ischemia
- •26.7 Popliteal Artery Entrapment Syndrome (PAES)
- •26.8 Genicular Artery Embolization (GAE)
- •References
- •27.1 Introduction
- •27.2 Relevant Anatomy
- •27.3 Varicose Veins
- •27.3.1 Clinical Evaluation
- •27.3.2 Physical Examination
- •27.3.3 Sonological Evaluation
- •27.3.3.1 Duplex Sonographical Evaluation
- •27.3.5.1 Thermal Ablation
- •Endovenous Laser Ablation
- •Radiofrequency Ablation
- •Endovenous Steam Ablation
- •27.3.5.2 Non-thermal Ablative Methods
- •Foam Sclerotherapy
- •Cyanoacrylate Closure (CAC)
- •Mechanochemical Ablation (MOCA)
- •Cryosclerosis
- •27.4 Deep Vein Thrombosis
- •27.4.1 Diagnosis
- •27.4.1.1 Pre-Test Probability
- •27.4.1.2 D-Dimer Assessment
- •27.4.1.3 Radiological Evaluation
- •27.4.5.1 Catheter-Directed Thrombolysis
- •Single-Session (Second-Generation) Pharmacomechanical Catheter-Directed Thrombolysis
- •27.5.1 Pulmonary Embolism (PE)
- •27.5.2 Clinical Features
- •27.5.3 Imaging Evaluation
- •27.5.4 Management
- •27.5.5 Endovascular Techniques
- •References
- •28.1 Introduction
- •28.3.2 Imaging Evaluation
- •28.4 Endovascular Management
- •28.4.1 Nonmature Fistulas
- •28.4.3 Acute Thrombosis
- •28.5 Central Venous Stenosis
- •28.7 Pseudoaneurysm
- •References
- •29.1 Introduction
- •29.2 Low-Flow Vascular Malformations
- •29.2.1.1 Pre-procedural Requirements
- •29.2.1.2 Procedure
- •29.2.1.3 Post-procedure Care
- •Ethanol
- •Detergent Sclerosant
- •Bleomycin
- •Doxycycline
- •OK-432 (Picibanil)
- •29.2.1.5 Complications
- •29.3 High-Flow Vascular Malformations
- •29.3.1.1 Pre-procedure Evaluation
- •29.3.1.2 Technique
- •29.3.1.3 Complications
- •29.4 Fibro-Adipose Vascular Anomaly (FAVA)
- •29.5 Conclusion
- •References
- •30.1 Introduction
- •30.2 Splenic Injuries
- •30.2.2 Technique
- •30.2.3 Patient Preparation
- •30.2.4 Procedure
- •30.2.5 Embolizing Agent
- •30.2.6 Post-procedural Care
- •30.2.7 Complication
- •30.3 Hepatic Injury
- •30.3.1 Background
- •30.3.2 Indication
- •30.3.3 Technique
- •30.3.4 Patient Preparation
- •30.3.6 Embolization Agent
- •30.3.7 Post-procedural Care
- •30.3.8 Complications
- •30.4 Peripheral Vascular Injuries (PVI)
- •30.4.1 Background
- •30.4.2 Indication
- •30.4.3 Patient Preparation
- •30.4.5 Embolization Agent
- •30.4.6 Post-procedural Care
- •30.4.7 Complications
- •30.5 Pelvic Trauma
- •30.5.1 Background
- •30.5.2 Indication
- •30.5.3 Technique
- •30.5.4 Patient Preparation
- •30.5.6 Embolization Agent
- •30.5.7 Complications
- •30.6 Maxillofacial Injury (MFI)
- •30.6.1 Background
- •30.6.2 Indication
- •30.6.3 Technique
- •30.6.4 Patient Preparation
- •30.6.6 Embolization Agent
- •30.6.7 Complications
- •30.7 Conclusion
- •References
- •31.1 Introduction
- •31.2 Inferior Petrosal Sinus Sampling
- •31.2.2 Cushing Syndrome (CS)
- •31.2.4 Pre-Procedure Instructions
- •31.2.5 Minimum Hardware Required
- •31.2.7 Result Interpretation
- •31.3 Adrenal Venous Sampling
- •31.3.1 Adrenal Gland Anatomy
- •31.3.2 Vascular Anatomy
- •31.3.3 Primary Hyperaldosteronism
- •31.3.5 Pre-Procedure Instructions
- •31.3.6 Minimum Hardware Required
- •31.3.8 Result Interpretation
- •31.4 Pancreatic Venous Sampling
- •31.4.1 Pancreatic Venous Anatomy
- •31.4.3 Pancreatic Neuroendocrine Tumors
- •31.4.4 Pre-Procedure Instructions
- •31.4.5 Minimum Hardware Required
- •31.4.7 Result Interpretation
- •31.5 Ovarian Venous Sampling
- •31.5.1 Anatomy
- •31.5.2 Hyperandrogenism
- •31.5.3 Pre-Procedure Instructions
- •31.5.4 Minimum Hardware Required
- •31.5.6 Result Interpretation
- •31.6.1 Anatomy
- •31.6.2 Pre-Procedure Instructions
- •31.6.3 Minimum Hardware Required
- •31.6.4 Procedure
- •31.6.5 Result Interpretation
- •31.7.1 Pre-Procedure Instructions
- •31.7.2 Minimum Hardware Required
- •31.7.3 Procedure
- •31.7.4 Result Interpretation
- •31.8 Conclusion
- •References
- •32.1 Introduction
- •32.2 Priapism
- •32.3 Erectile Dysfunction
- •32.3.2 Epidemiology
- •32.3.3 Aetiology
- •32.3.4 Pathophysiology
- •32.3.6 Imaging
- •32.3.7 Relevant Anatomy
- •32.3.7.2 Venous Anatomy
- •32.3.8 Penile Doppler
- •32.4.1 Indications
- •32.4.2 Contraindications
- •32.4.3 Equipment
- •32.4.4 Technical Aspects
- •32.4.5 Procedure Timing
- •32.4.6 Outcomes
- •32.4.7 Complications
- •32.4.8 Post-Procedural Care
- •32.5.1 Indications
- •32.5.2 Contraindications
- •32.5.3 Equipment
- •32.5.4 Technical Aspects
- •32.5.5 Outcomes
- •32.5.6 Complications
- •32.6.1 Indications
- •32.6.2 Contraindications
- •32.6.3 Equipment
- •32.6.4 Procedural Planning
- •32.6.5 Technical Aspects
- •32.6.6 Outcomes
- •32.6.7 Complications
- •32.7 Conclusion
- •References
- •33: Image-Guided Biopsy
- •33.1 Introduction
- •33.2 Biopsy Devices
- •33.3 Pre-Procedural Evaluation
- •33.4 Ultrasound-Guided Biopsy
- •33.5 CT-Guided Biopsy
- •33.6 MRI-Guided Biopsy
- •33.7.2 Breast
- •33.7.3 Lung
- •33.7.4 Mediastinum
- •33.7.5 Liver
- •33.7.6 Gallbladder
- •33.7.7 Spleen
- •33.7.8 Bowel
- •33.7.9 Retroperitoneum
- •33.7.11 Pelvis
- •33.7.12 Spine
- •33.7.13 Extremities
- •33.8 Conclusion
- •References
- •34: Image-Guided Drainage Procedures
- •34.1 Introduction
- •34.2 Etiology
- •34.4 Contraindications
- •34.5 Imaging Modalities
- •34.6 Pre-Procedure Evaluation
- •34.8 Post-Procedure Care
- •34.9 Complications
- •34.10.1 Postoperative Fluid Collection
- •34.10.2 Ascites
- •34.10.3 Liver Abscess
- •34.10.4 Peripancreatic Fluid Collection
- •34.10.5 Splenic Abscess
- •34.10.6 Appendicitis
- •34.10.8 Renal Abscess
- •34.10.9 Pelvic Abscess
- •34.10.10 Prostatic Abscess
- •34.11 Summary
- •References
- •35: Ablation Techniques
- •35.1 Introduction
- •35.2 Chemical Ablation
- •35.3 Thermal Ablation Techniques
- •35.3.1 Radiofrequency Ablation
- •35.3.2 Microwave Ablation
- •35.3.3 Cryoablation
- •35.3.4 High-Intensity Focused Ultrasound
- •35.3.5 Laser Ablation
- •35.4 Non-thermal Ablation Techniques
- •35.4.1 Irreversible Electroporation
- •35.6.1 Liver
- •35.6.2 Kidney
- •35.6.3 Lung
- •35.6.4 Breast
- •35.6.5 Thyroid
- •35.6.6 Musculoskeletal System
- •35.6.7 Nerve Ablation
- •35.7 Conclusion
- •References
- •36.1 Introduction
- •36.3 CT-Guided Biopsy
- •36.3.2 Complications
- •36.3.3 Technical Approaches
- •36.3.4.3 Paramaxillary Approach
- •36.3.4.4 Submastoid Approach
- •36.3.4.5 Transoral Approach
- •36.3.5.1 Anterolateral Approach
- •36.3.5.2 Posterolateral Approach
- •36.3.5.3 Posterior Approach
- •36.4 Ultrasound-Guided Biopsy/FNAC
- •36.4.2.5 Carotid Space
- •36.7 Conclusion
- •References
- •37: Nonvascular Thoracic Interventions
- •37.1 Introduction
- •37.2 Thoracic Drainage Procedures
- •37.2.1 Pre-Procedure Evaluation
- •37.2.2 Imaging
- •37.3 Thoracocentesis
- •37.3.1 Indications
- •37.3.2 Relative Contraindications
- •37.3.4 Technique
- •37.4.1 Indications
- •37.4.2 Contraindications
- •37.4.3 Drain Size
- •37.4.5 Post-Insertion Care
- •37.5 Intrapleural Fibrinolytic Therapy
- •37.5.1 Catheter Removal
- •37.6 Practice Points
- •37.7 Indwelling Pleural Catheter Insertion
- •37.7.1 Duration
- •37.8.1 Procedure
- •37.8.2 Trocar Drainage
- •37.8.3 Seldinger Technique
- •37.8.4 Post-Procedure Follow-Up
- •37.8.5 Removal
- •37.9 Complications
- •37.9.1 Thoracentesis Related
- •37.9.2 Drainage Chest Tube Related
- •37.9.3 IPC Related
- •37.11.1 Pre-Procedure Evaluation
- •37.11.3 Technique
- •37.11.4 Post-Procedure Care
- •37.11.5 Complications [11, 14, 15]
- •37.12.1 Indications [11, 19]
- •37.12.2 Contraindications [11, 19]
- •37.12.3 Technique
- •37.12.4 Post-Procedure Care
- •37.12.5 Complications
- •References
- •38.1 Introduction
- •38.2 Biliary Anatomy
- •38.3 Biliary Obstruction
- •38.4 Percutaneous Transhepatic Biliary Drainage
- •38.4.2 Indications
- •38.4.3 Contraindications
- •38.4.4 Technique
- •38.4.5 Post-Procedure Care
- •38.4.6 Complications
- •38.5 Biliary Stenting
- •38.5.1 Indications
- •38.5.2 Technique
- •38.7 Intraluminal Procedures Through Percutaneous Biliary Access
- •38.7.1 Endobiliary Biopsy
- •38.7.2 Intraluminal Brachytherapy
- •38.7.3 Gallstone Extraction
- •38.8 Percutaneous Cholecystostomy
- •38.8.1 Indications
- •38.8.2 Technique
- •References
- •39.1 Introduction
- •39.2 Percutaneous Gastrostomy
- •39.2.1 Indications
- •39.2.2 Contraindications
- •39.2.3 Pre-procedural Work-Up
- •39.2.4 Technique
- •39.2.6 Pull-Type PRG
- •39.3 Percutaneous Jejunostomy
- •39.3.1 Indications
- •39.3.2 Technique
- •39.4 Percutaneous Cecostomy
- •39.4.1 Indications
- •39.4.2 Technique
- •39.4.3 Post-procedure Care
- •39.5.1 Technique
- •39.6.1 Technique
- •39.6.3 Malignant Tracheoesophageal Fistula Stenting
- •39.6.5 Complications
- •References
- •40.1 Introduction
- •40.2 Percutaneous Nephrostomy (PCN)
- •40.2.5 Post-procedure Care
- •40.4.3 Ureteroarterial Fistula
- •References
- •41.1 Introduction
- •41.2 Fallopian Tube Recanalization (FTR)
- •41.2.1 Technique
- •41.2.2 Complications
- •41.2.3 Results
- •41.3 Amniocentesis
- •41.3.1 Indications
- •41.3.2 Contraindications [7]
- •41.3.4 Technique
- •41.3.5 Complications
- •41.4 Chorionic Villous Sampling (CVS)
- •41.4.1 Indications
- •41.4.2 Contraindications
- •41.4.4 Technique
- •41.4.5 Complications
- •41.5.1 Indications [15–19]
- •41.5.2 Contraindications [20–23]
- •41.5.3 Technique [15, 23]
- •41.5.4 Complications [15, 23, 24]
- •41.5.5 Outcome [23]
- •41.6.1 Technique
- •41.6.2 Complications
- •41.7.1 Contraindications
- •41.7.2 Technique
- •41.7.3 Complications
- •41.8.1 Technique
- •41.8.2 Complications
- •41.9.1 Technique
- •41.9.2 Complications [28, 44, 45]
- •References
- •42.1 Introduction
- •42.2 Breast Biopsy
- •42.2.2 USG-Guided Biopsy [1, 2]
- •42.2.3 MG-Guided Biopsy [3, 4]
- •42.2.4 MRI-Guided Biopsy [1, 11–13]
- •42.2.5 Vacuum-Assisted Biopsy [1, 4, 14, 15, 16]

316
V. Kubihal et al.
Erectile dysfunction: Penile vasodilation with intracavernosal injection 15 microgram of prostaglandin E1 can be
used to improve angiographic quality and detection of lesion.
In patients with signicant stenosis of penile artery, pudendal artery, or internal iliac arteries, restoration of arterial supply can be done by angioplasty and/or stenting. Stenting is
preferred in presence of persistent stenosis with greater than
30% luminal narrowing after 10min pre-dilatation. Internal
pudendal artery angiogram is performed to conrm the restoration of penile blood ow. Patient is evaluated at follow up using international index of erectile function, and clinical
improvement is considered if there is increase in score by 4
or more [41, 44, 45].
25.6.3 Complications
Major complications are rare. Penile gangrene, erectile dysfunction, and gluteal ischemia are rare complication following embolization for high-ow priapism. Arterial dissection
following angioplasty for erectile dysfunction is rare and can
cause signicant stenosis or complete occlusion of the vessel. Minor complications such as puncture site hematoma
can be seen [46, 47].
25.6.4 Outcome
Embolization in high-ow priapism has a technical success
40%. Erectile capacity is restored in nearly 88% of patients
[43].
Angioplasty with or without stenting for erectile dysfunction is associated with clinical improvement rate between
54.5 and 60%. Restenosis is seen in 34.4–40% of patients
[46].
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Interventions oftheExtremity Arteries
MansiVerma andNirajNirmalPandey
26
Key Messages
1. Resting ankle brachial index (ABI) is recommended as
the rst line test for screening and diagnosis of peripheral arterial disease (PAD).
2. Imaging is only recommended to diagnose anatomical
location and severity of stenosis in symptomatic patients,
planned for revascularization.
3. The initial management strategies include optimal medical therapy, risk factor modication, and supervised
exercise program.
4. The indications for revascularization include patients
with limb-threatening ischemia, lifestyle limiting claudication, and claudicants with inadequate response to
optimal medical therapy and graded exercise program.
5. Revascularization can be done by endovascular means
(e.g., percutaneous transluminal angioplasty or stenting)
or open surgery (e.g., bypass).
6. The decision on endovascular or surgery rst has to be
individualized based on case-to-case basis depending on
location of lesions, morphology of lesions, complexity
of lesions, patient’s co-morbidities, and life expectancy.
7. In case of discrete and ostial stenosis of common iliac
artery (CIA) or external iliac artery (EIA), stenting may
be preferred.
8. In cases of diffuse disease of CIA, multiple stenosis, and
chronic total occlusions, stenting is more appropriate.
9. For short segment stenosis of supercial femoral artery
SFA and popliteal artery (<10cm) balloon angioplasty
rst is appropriate; however, in cases of stenosis, >10cm
stenting or drug eluting balloons/stents are preferred.
M. Verma
Department of Radio-diagnosis, Indira Gandhi Medical College &
Hospital, Shimla, Himachal Pradesh, India
N. N. Pandey (
Department of Cardiovascular Radiology and Endovascular
Interventions, All India Institute of Medical Sciences,
New Delhi, India
*)
10. Regardless of length of lesion, balloon angioplasty is
considered the endovascular technique of choice in
infra-popliteal lesions.
26.1 Relevant Anatomy ofLower Limb
Arteries
The lower limb arterial supply arises from the external iliac
artery (EIA), a continuation of the common iliac artery (CIA)
which is a terminal branch of the abdominal aorta. The external iliac artery continues as the common femoral artery
(CFA) beyond the inguinal ligament. The CFA then descends
in the proximal thigh on the anteromedial aspect in the femoral triangle [1]. Femoral triangle is formed by the inguinal
ligament superiorly, adductor longus muscle medially, and
sartorius muscle laterally. The common femoral vein lies on
the medial aspect of CFA. The CFA gives small branches
prior to bifurcation, namely the supercial epigastric artery,
external pudendal artery, and supercial circumex artery.
The CFA bifurcates into supercial femoral and deep femoral artery or profunda femoris artery. The profundal femoris
artery gives rise to medial and lateral circumex femoral
arteries and perforators to thigh muscles. The SFA continues
along the medial aspect of the thigh and passes through the
adductor canal in the distal part. After exiting the adductor
canal, it passes posterior to the femur and is known as the
popliteal artery. The SFA gives off the descending genicular
branch prior to its exit from the adductor hiatus, and the popliteal artery supplies the knee joint by giving superior and
inferior genicular arteries on either side. The popliteal artery
is divided into three segments: P1 from the intercondylar
fossa to the proximal patella, P2 from the proximal patella to
the center of the knee joint, and P3 from the center of the
knee joint till the origin of an anterior tibial artery [2].
At the level of the proximal tibiobular joint, the popliteal
artery bifurcates into an anterior tibial artery and tibioperoneal
trunk. The anterior tibial artery courses laterally and continues
in the foot as the dorsalis pedis artery. Tibioperoneal trunk
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_26
319

320
M. Verma and N. N. Pandey
bifurcates into posterior tibial artery and peroneal artery. The
posterior tibial artery gives rise to medial and lateral plantar
arches. The plantar arch forms metatarsal and plantar digital
arteries which communicate between the arches to the dorsalis
pedis artery. Above the level of the ankle, joint peroneal artery
terminates into medial and lateral calcaneal branches [1].
26.2 Peripheral Arterial Disease (PAD)
26.2.1 Introduction
Peripheral arterial disease (PAD) is characterized by stenotic
or occlusive arterial disease with decreased blood ow to
limbs. Approximately 50% PAD patients are asymptomatic
[3]. About 10–35% patients have typical claudication and
1–3% develop critical limb ischemia [4]. Various classication schemes have been developed for PAD with stratication based on clinical presentation, anatomic distribution, or
a combination of clinical factors.
26.2.2 Classication Systems
26.2.2.1 Clinical Classication
The clinical presentation of PAD can be categorized as:
asymptomatic, intermittent claudication, critical limb ischemia (CLI), and acute limb ischemia (ALI).
26.2.2.2 Fontaine Classication
This classication system is based on clinical presentation
without other diagnostic tests and is not routinely used [5].
Grade Symptoms
Stage I Asymptomatic
Stage II Intermittent claudication
Stage IIA Claudication distance >200m
Stage IIB Claudication distance <200m
Stage III Rest pain
Stage IV Ischemic ulcer/gangrene
26.2.3 Rutherford Classication forChronic
Limb Ischemia
Apart from clinical symptoms, objective ndings such as
Doppler, ankle-brachial index (ABI), and pulse volume
recordings are also included [6].
Category Clinical description
0 Asymptomatic
1 Mild claudication
2 Moderate claudication
3 Severe claudication
4 Ischemic rest pain
Category Clinical description
5 Minor tissue loss: Ischemic ulcers or focal gangrene
not exceeding the digits of the foot
6 Major tissue loss: Extending above transmetatarsal level
26.2.4 Anatomical Classication
Trans-Atlantic Inter-Society Consensus Document II
(TASC II)
Fourteen societies from North America and Europe in 2000
formed a consensus regarding the classication and management of patients with PAD (TASC I). This was later updated
in 2007 with more international representatives, and more
emphasis on diabetes and PAD, and led to a reclassication of
complex anatomies into the less severe categories [4]. TASC
II divides the anatomic distribution of lesions into aorto-iliac
and femoral-popliteal. Lesion patterns are grouped into A–D
lesions and accordingly provided guidance on treatment decisions in terms of optimal revascularization strategy [4].
TASC A: Endovascular therapy is the treatment of choice
TASC B: Endovascular treatment is preferred
TASC C: Surgery is preferred
TASC D: Surgery is the treatment of choice
A supplement to TASC II in 2015 incorporated the recent
advances in endovascular techniques that have resulted in
paradigm shift toward endovascular approach for even the
most complex lesions (TASC D) and also added the infrapopliteal classication.
26.2.5 Diagnostic andImaging Modalities
26.2.5.1 Non-imaging/Functional Modalities
Resting ABI (ankle brachial index) is the rst-line test for
screening and diagnosis of PAD [7]. The interpretation of
ABI is as follows: ≤0.90: abnormal; 0.91–0.99: borderline;
1.00–1.40: normal; >1.40: non-compressible [8]. Toe brachial index (TBI) and pulse volume recordings may be measured in patients with suspected PAD and ABI >1.4 [9].
26.2.5.2 Imaging Evaluation
Imaging evaluation is not recommended for the diagnosis of
PAD. Imaging is performed to diagnose anatomical location
and severity of stenosis in symptomatic patients, planned for
revascularization. Doppler Ultrasound is the rst-line imaging
method to conrm PAD [9]. However, it is less accurate in the
evaluation of aortoiliac segment, multilevel stenosis, and infrapopliteal disease. It does not provide full arterial imaging as a
road map. Magnetic resonance angiography (MRA)/computed
tomographic angiography (CTA) is indicated for anatomical
localization and guiding revascularization. Both these modali-

26 Interventions oftheExtremity Arteries
321
ties provide a road map of arterial tree and aid in planning further interventions. MRA can even be performed without contrast
and is not affected by artifacts generated by heavily calcied
vessels. So MRA should be preferred over CTA for further anatomical characterization [9]. The diagnostic algorithm for the
evaluation of patients with PAD is summarized in Fig.26.1.
26.2.6 Management Strategies
26.2.6.1 Optimal Medical Therapy, Risk Factor
Modication, andSupervised Exercise
Program
The goal is to reduce the risk of cardiovascular events and
improve the functional status of the limb. Aspirin or clopido-
Fig. 26.1 Diagnostic
algorithm for evaluation of
peripheral arterial disease
Resting ABI : first
(Class 1)
grel is prescribed to reduce the risk of death, myocardial
infarction, or stroke in symptomatic PAD patients and in
asymptomatic patients with ABI <0.9 [7]. Statins are indicated for all patients irrespective of cholesterol level with the
goal of therapy to attain LDL <70mg/dl [9]. There should be
optimum glucose and blood pressure control, and the patients
who smoke are advised to quit smoking. Supervised exercise
program relieves the symptoms in patients with intermittent
claudication, and cilostazole improves the walking distance
in claudicants [9]. The various management strategies are
summarized in Fig.26.2.
History and physical
examination
line test
Suspect CLI in presence
of rest pain, ischemic
ulcer or gangrene
Fig. 26.2 Management
strategies in evaluation of
peripheral arterial disease
Abnormal
ABI <0.9
Imaging in
symptomatic
patients when
revascularization
contemplated
Asymptomatic patients
GOAL: CV risk factor
modification
Medical therapy
Lifestyle modification
ABI: Normal or borderline
With exertional non joint related
symptoms
Exercise
ABI
(class 1)
If abnormal
Diagnosis of PAD is made
DUS : first line imaging method to confirm diagnosis (class I)
MRA / CTA : anatomical characterization (class I)
Diagnosis of PAD
confirmed
Intermittent claudication
GOAL: CV risk factor
modification, improving
functional status of limb
Medical therapy including
cilostazole, Life style
modification, Exercise
Incompressible
ABI >1.4
TBI or PVR's
(class 1)
If abnormal
Critical limb ischemia
GOAL: LIMB SALVA GE
Medical therapy, Life
style modification
Lifestyle limiting claudication
inadequate response to medical therapy
Revascularization
Priority basis

322
M. Verma and N. N. Pandey
26.2.6.2 Indications ofRevascularization
These include limb-threatening ischemia (rest pain/tissue
loss), inadequate response to optimal medical therapy, and
graded exercise program in claudicants and lifestyle-limiting
or disabling claudication.
26.2.6.3 Revascularization Strategies
Revascularization can be performed by endovascular method
(e.g., percutaneous transluminal angioplasty or stenting) or
open surgery (e.g., bypass). Bypass utilizes autologous vein
grafts or prosthetic materials.
The decision to perform endovascular or surgery rst is
individualized on a case-to-case basis taking into account the
location of the lesion, morphology, and complexity of the
lesion, patient’s comorbidities, and life expectancy. The
endovascular technique is preferred for short lesions and stenosis. Surgery is preferred in long diffuse lesions, occlusions, and extensive circumferential calcication.
26.3 Endovascular Revascularization:
Angioplasty andStenting
26.3.1 Evidence-Based Guidelines
forPeripheral Arterial Interventions
According to appropriateness criteria, in case of discrete and
ostial stenosis of CIA or EIA, stenting may be preferred. In
cases of diffuse disease of CIA, chronic total occlusion, and
multiple stenosis, primary stenting is more appropriate [10].
For short segment stenosis of SFA and popliteal artery
(<10cm), balloon angioplasty rst is appropriate; however,
in cases of stenosis >10cm stenting or drug-eluting balloons/
stents are preferred [10]. Regardless of length of lesion, balloon angioplasty rst is considered the endovascular technique of choice in infra-popliteal lesions. The algorithms for
the management of peripheral arterial disease according to
the European Society of Cardiology/European Society of
Vascular Surgery are summarized in Figs. 26.3, 26.4, and
26.5 [7].
26.3.2 Preprocedural Evaluation
History and physical examination should be performed. The
quality of pulses of bilateral extremities as well as the presence of ulcer or gangrene should be documented. There are
various patient- and lesion-specic factors that predict
adverse outcomes after endovascular revascularization.
Patient-specic factors include diabetes mellitus, smoking,
chronic kidney disease, critical limb ischemia, and major tissue loss. The various anatomical parameters that are evaluated in imaging studies include the location of the lesion,
length of lesion, stenosis or occlusion, presence of calcication or thrombus, multiple lesions, status of inow vessels,
and distal runoff [11]. Baseline ABI should be performed
prior to the procedure. Before performing endovascular
revascularization, adequate glycemic control and smoking
cessation should be ensured. 75mg aspirin and clopidogrel
is started 3–5 days prior to the procedure. The laboratory
investigations should include complete blood count, PT/
INR, renal function test, and potassium levels in case of
major tissue loss. Prophylactic antibiotics are not routinely
administered prior to peripheral arterial interventions.
Fig. 26.3 Diagnostic
algorithm for aorto-iliac
lesion
Short (<5 cm) iliac
stenosis/ occlusion
Endovascular
first (I C)
Angioplasty
+/- primary
stenting
(Ila B)
Long occlusions
bilateral lesions
High surgical
risk
severe co-
morbidities
Endovascular
approach
(Ila B)
Aorto-iliac lesion
Fit for
surgery
Aorto-femoral
bypass (Ila B)
Iliac lesion
extending
till CFA
Hybrid
approach
(Ila C)
Occlusion of
infrarenal
aorta till iliac
level
Open surgery
in fit patients (Ila C)
Endovascular
approach in
patients with high
surgical risk

26 Interventions oftheExtremity Arteries
323
Fig. 26.4 Diagnostic
algorithm for femoropopliteal lesion
stenosis/ occlusion of
SFA < 25 cm
Endovascular first (I C)
Angioplasty +/- primary
stenting
(Ila A)
DEB (IIb A)
DES (IIb B)
Infrapopliteal
lesion
Isolated crural
lesion in
claudicant
Medical therapy
Exercise
Bypass
using GSV
(IA)
Fig. 26.5 Diagnostic algorithm for infrapopliteal lesion
Infrapopliteal
lesion with CLI
Revascularization
for limb salvage
(I C)
Endovascular
approach
(Ila B)
26.3.3 Technique ofAngioplasty inPeripheral
Arterial Disease
The hardware required include puncture needle, different
guidewires, catheters, angioplasty balloons, and stents.
Depending on the location of the lesion and the ease of crossing it, the various access that can be taken include retrograde
access via CFA, ipsilateral CFA access, retrograde popliteal,
tibial-pedal, and upper limb access. The advantages of antegrade CFA approach in femoropopliteal interventions are
direct and complete transmission of force with increased
Femoro-popliteal
lesion
High surgical
risk
No vein
Endovascular
approach
(Ilb C)
> 25 cm occlusions
Reocclusion of SFA
Fit for surgery
Vein material +
Life expectancy
>2 yrs
Femoropopliteal bypass
(I B)
Use of autologous
saphenous vein (IA)
Associated
CFA lesion
Hybrid
approach
pushability, torquebility, and maneuverability [12]. The various predictors of needing retrograde tibial-pedal access (or
combination of antegrade and retrograde) include chronic
total occlusion (CTO) caps with antegrade convex conguration, severe calcication, and longer length lesion [13].
Intervention should be performed using an appropriately
sized sheath and systemic anticoagulation achieved with
intravenous heparin. For contralateral interventions, crossover sheath is advanced over iliac bifurcation. A diagnostic
arteriogram should be performed rst which can be tailored
based on pre-procedural cross-sectional imaging. Lesion signicance can be determined by hemodynamic gradient measurements or diameter reduction measurement. Generally,
resting mean trans-lesional gradient >5mm Hg or systolic
gradient >10mm Hg is considered signicant.
After crossing the lesion with a suitable guidewirecatheter combination, distal runoff should be assessed.
Balloon angioplasty is performed using an optimal sized balloon (based on normal reference diameter) with length spanning from normal-to-normal segment. Approximate
placement of balloon can be conrmed with contrast injection and uoroscopic landmarks. The balloon pressure is
slowly increased using insufator, and ination for approximately 1 minute is performed at the nominal pressure.
Nominal pressure is dened as the pressure at which the balloon is inated to achieve the listed balloon diameter. Rated
burst pressure (RBP) is the pressure below which 99.9% of
the balloons will not burst upon single ination. Ination at
high pressures may be required in recurrent, residual, and
heavily calcied lesions. Resolution of waist denotes adequacy of dilatation. After deation and removal of balloon,
completion angiogram including distal runoff should be

324
cd
M. Verma and N. N. Pandey
taken to determine technical success and exclude complications such as arterial rupture, dissection, and distal embolization [14]. Care is taken to maintain guidewire across the
lesion till completion angiogram to preserve treatment
options in case of inadvertent complications. The number of
lesion traversals with wires and catheters should be minimized to avoid distal complications. Postprocedural pressure
gradient may be performed if necessary.
26.3.4 End Points ofAngioplasty
Imaging: Residual stenosis less than 30%
Hemodynamic: Reduction in the pressure gradient to less
than 5mm Hg mean or 10mm Hg systolic
Clinical: Restoration of 2+ CFA or DPA pulses
Improvement in post-intervention ABI by 0.15 [14].
26.3.5 Complications
Dissection ap: In case of non-obstructive ap, a lowpressure prolonged balloon tacking can be done. However, in
case of ow-limiting dissection, stent needs to be placed.
Arterial rupture: In cases of arterial rupture, resuscitation
should be started immediately with intravenous uids, pressor agents, reversal of anticoagulation with protamine, and
blood transfusion. A balloon should be inated immediately
covering the rupture site, and covered stents are required to
exclude the perforation site.
Distal atheroembolism: The emboli can be resolved using
catheter suction, aspiration devices, and thrombolytics.
26.3.6 Stenting
Provisional stenting is indicated for technically unsuccessful
angioplasty (>30% residual stenosis or residual gradient
>5mm) or in case of complications like ow-limiting dissection or vessel perforation (Fig.26.6). Primary stenting may
be more appropriate in selected lesions such as chronic total
occlusions and long lesions.
Stent length should be sufcient to cover the lesion.
Measurement can be obtained from prior cross-sectional
imaging or using digital angiography calibrated to standardized catheters. The stents can be balloon-mounted or selfexpandable. Balloon-mounted stents are deployed by inating
the balloon, whereas in self-expandable (SE) stents, withdrawing the outer sleeve covering the collapsed stent initiates
the deployment. SE stents usually require post- dilatation with
a balloon. As is the case with angioplasty, post-deployment
angiogram with assessment of distal run- off is performed.
SE stents composed of nitinol or Elgiloy have property of
shape memory. They possess greater exibility, conformability, and crush resistance. Hence, they are preferred in tortuous iliac lesions, lesions in proximity to joints, and long
segment disease. Care should be taken while using SE stents
which shorten after deployment and are more difcult to precisely place, for example in bifurcation or ostial lesion.
Stenting should be avoided across the joint owing to external
mechanical stresses. However, in selected situations, SE vasculomimetic stents can be placed (Fig. 26.7). Balloonexpandable (BE) stents have higher radial force with precise
placement. BE stents are preferred in ostial, aortic bifurcation, and severely calcied lesions [15]. However, BE stents
can dislodge from balloon, are more rigid, and have no elas-
ab
Fig. 26.6 A 53-year-old man with bilateral intermittent claudication.
Computed tomography angiography (a) revealed signicant right common iliac artery (CIA) stenosis with left CIA occlusion. Kissing bal-
loon angioplasty (b) was performed with residual stenosis in bilateral
CIA (c) followed by placement of stents bilaterally (d)

26 Interventions oftheExtremity Arteries
abc
325
Fig. 26.7 A 56-year-old man with intermittent claudication in left leg.
Digital subtraction angiography revealed (a) diffuse signicant stenosis
with lling defects suggestive of thrombus involving supercial femo-
tic memory that precludes their use in areas with external
forces.
Stent grafts (covered stents) are composed of synthetic
material such as polytetrauoroethylene (PTFE) covering
the stent. They can be SE or BE.Stent grafts reduce restenosis and are mainly used in cases of arterial ruptures and
aneurysms.
26.3.7 Post-Procedure
Serial vascular examinations, ABI, and follow-up Doppler
are performed as per institutional policy. Dual antiplatelet is
prescribed after stent placement (75mg aspirin and 75mg
clopidogrel) for 1 month followed by aspirin lifelong.
Smoking cessation, blood pressure control, and lipid optimization should be aggressively followed.
26.4 Technical andClinical Outcomes
Aortoiliac Segment In a meta-analysis of the results of
percutaneous angioplasty and stenting in aortoiliac occlusive disease, technical success and four-year primary
ral artery and multiple collaterals. Balloon angioplasty was performed
further (b) with placement of Supera vasculomimetic stent (c)
patency rates were higher with primary stenting [16]. In the
Dutch Iliac Stent Trial (DIST) study that randomized
patients to either angioplasty with selective stenting or primary stenting, there was no signicant difference in patency
outcomes in early or long term; however, 43% patients
eventually required secondary stent placement [17]. In
another randomized clinical trial of stents versus angioplasty in treatment of iliac artery occlusions (STAG trial),
primary stent placement increased technical success and
decreased major procedural complications as compared to
balloon angioplasty [18]. In the covered versus balloon
expandable stent trial (COBEST), covered stents performed
better in TASC C and D lesions as compared to bare stents
in the long-term patency and clinical outcome [19]. But the
disadvantages with covered stents include thrombotic occlusion, occlusion of side branches, and edge restenosis. In a
comparative study, primary patency rates after iliac stenting
in TASC B/C lesions were 85%, 72%, and 64% at 1, 3, and
5years, whereas the rates were 89%, 86%, and 86%, respectively, after surgical reconstruction [20]. In a recent metaanalysis of direct surgical versus endovascular
revascularization for aortoiliac occlusive disease, primary
patency, secondary patency, and overall survival favored
direct surgical group [21].

326
M. Verma and N. N. Pandey
Femoropopliteal Segment In a meta-analysis of endovascular versus surgical reconstruction, the primary patency at
1year in surgical group was 72% versus 62% in endovascular group. There was no signicant difference in terms of
patency at 4years and overall survival [22]. Self-expandable
nitinol stents were superior to angioplasty in a study by
these mechanical stresses, there is a risk of complications
such as stent fracture, restenosis, and thrombosis, hence the
need for vasculomimetic stent like LifeStent and Supera. In
the SUPERB trial when the stent is deployed to the intended
length, the 12-month primary patency was 90% with main-
tained durability through 36months [27].
Schillinger et al.’s RESILIENT trial and DURABILITY
study [23–25]. However, the superiority was not proven in
FAST and SUPER trials. A meta-analysis of randomized
controlled trials supported the role of primary stenting
mainly in long lesions with no statistical difference in target
lesion revascularization and mortality as compared to balloon angioplasty with optional stenting [26]. Femoropopliteal territory is subjected to complex external
mechanical stresses as exion, compression, and torsion.
The distal part traverses the adductor canal which further
increases the compression during thigh contraction. Due to
Below Knee Lesions In a randomized controlled trial com-
paring bypass versus plain balloon angioplasty, there were
no statistically signicant differences in amputation-free sur-
vival or overall survival in the follow-up among the two
strategies [28]. In a meta-analysis of angioplasty versus
stenting, there was no clear difference in short-term patency,
complication rate, major amputation, and mortality between
treatment groups [29]. Hence, the preferred endovascular
approach is angioplasty with stenting reserved for bailout
situations (Fig.26.8).
abcd
Fig. 26.8 A 57-year-old man presented with rest pain and ischemic
ulcer in right foot. Digital subtraction angiogram (a) revealed diffuse
signicant disease in right posterior tibial artery (PTA). Angioplasty of
right PTA was performed (b, c) followed by bioresorbable stent place-
ment in distal PTA
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