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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 signicant 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 10min pre-dilatation. Internal pudendal artery angiogram is performed to conrm 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 signicant 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].

References

1. Das CJ, Rathinam D, Manchanda S, Srivastava DN.Endovascular uterine artery interventions. Indian J Radiol Imaging. 2017;27(04):488–95.
2. Young M, Coffey W, Mikhail LN.Uterine broid embolization. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [cited 2022 Mar 29]. Available from: http://www.ncbi.nlm.
nih.gov/books/NBK519016/.
3. Andrews RT, Spies JB, Sacks D, Worthington-Kirsch RL, Niedzwiecki GA, Marx MV, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol. 2009;20(7):S307–11.
4. Brown M, Hong M, Lindquist J. Uterine artery embolization for primary postpartum hemorrhage. Tech Vasc Interv Radiol. 2021;24(1):100727.
5. Mara M, Fucikova Z, Maskova J, Kuzel D, Haakova L.Uterine broid embolization versus myomectomy in women wishing to
preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2006;126(2):226–33.
6. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O.Midterm clinical and rst reproductive results of a randomized controlled trial comparing uterine broid embolization and myo­mectomy. Cardiovasc Intervent Radiol. 2008;31(1):73–85.
7. Gupta JK, Sinha A, Lumsden MA, Hickey M.Uterine artery embo­lization for symptomatic uterine broids. Cochrane Database Syst Rev. 2014;2014(12):CD005073.
8. Zhang J, Go V-A, Blanck JF, Singh B. A systematic review of minimally invasive treatments for uterine broid-related bleeding. Reprod Sci Thousand Oaks Calif. 2021;114:e236.
9. Popovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA.Uterine artery embolization for the treatment of adenomyosis: a review. J Vasc Interv Radiol JVIR. 2011;22(7):901–9; quiz 909.
10. de Bruijn AM, Smink M, Lohle PNM, Huirne JAF, Twisk JWR, Wong C, et al. Uterine artery embolization for the treatment of adenomyosis: a systematic review and meta-analysis. J Vasc Interv Radiol. 2017;28(12):1629–1642.e1.
11. Loya MF, Garcia-Reyes K, Gichoya J, Newsome J.Uterine artery embolization for secondary postpartum hemorrhage. Tech Vasc Interv Radiol. 2021;24(1):100728.
12. Matsuzaki S, Lee M, Nagase Y, Jitsumori M, Matsuzaki S, Maeda M, et al. A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization. Sci Rep. 2021;11(1):16914.
13. Yang C-C, Chou Y-C, Kuo T-N, Liou J-Y, Cheng H-M, Kuo Y-T. Prophylactic intraoperative uterine artery embolization dur­ing cesarean section or cesarean hysterectomy in patients with abnormal placentation: a systematic review and meta-analysis. Cardiovasc Intervent Radiol. 2022;45(4):488–501.
14. Fowler ML, Wang D, Chia V, Handal-Orece R, Latortue-Albino P, Mulekar S, etal. Management of cervical ectopic pregnancies: a scoping review. Obstet Gynecol. 2021;138(1):33–41.
15. McWilliams JP, Bilhim TA, Carnevale FC, Bhatia S, Isaacson AJ, Bagla S, et al. Society of Interventional Radiology Multisociety Consensus Position Statement on Prostatic Artery Embolization for Treatment of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: From the Society of Interventional Radiology, the Cardiovascular and Interventional Radiological Society of Europe, Société Française de Radiologie, and the British Society of Interventional Radiology. J Vasc Interv Radiol. 2019;30(5):627–637.e1.
16. Picel AC, Hsieh T-C, Shapiro RM, Vezeridis AM, Isaacson AJ.Prostatic artery embolization for benign prostatic hyperplasia: patient evaluation, anatomy, and technique for successful treat­ment. Radiographics. 2019;39(5):1526–48.
17. Dias US Jr, de Moura MRL, Viana PCC, de Assis AM, Marcelino ASZ, Moreira AM, etal. Prostatic artery embolization: indications, preparation, techniques, imaging evaluation, reporting, and compli­cations. Radiographics. 2021;41(5):1509–30.
18. Teichgräber U, Aschenbach R, Diamantis I, von Rundstedt F-C, Grimm M-O, Franiel T. Prostate artery embolization: indication, technique and clinical results. RöFo– Fortschritte Auf Dem Geb Röntgenstrahlen Bildgeb Verfahr. 2018;190(09):847–55.
19. de Assis AM, Moreira AM, de Paula Rodrigues VC, Harward SH, Antunes AA, Srougi M, etal. Pelvic arterial anatomy relevant to prostatic artery embolisation and proposal for angiographic clas­sication. Cardiovasc Intervent Radiol. 2015;38(4):855–61.
20. Carnevale FC, Moreira AM, de Assis AM, Antunes AA, de Paula C, Rodrigues V, Srougi M, et al. Prostatic artery emboli­zation for the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia: 10 years’ experience. Radiology. 2020;296(2):444–51.
21. Macleod R, Biyani CS, Cartledge J, Eardley I. Varicocele. BMJ Clin Evid. 2015;2015:1806.
25 Interventions ofthePelvic Vessels
317
22. Masson P, Brannigan RE. The varicocele. Urol Clin North Am. 2014;41(1):129–44.
23. Baigorri B, Dixon R.Varicocele: A Review. Semin Interv Radiol. 2016;33(03):170–6.
24. Paduch DA, Skoog SJ.Current management of adolescent varico­cele. Rev Urol. 2001;3(3):120–33.
25. Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R.Percutaneous embolization of varicocele: technique, indications, relative contra­indications, and complications. Asian J Androl. 2016;18(2):234.
26. Johnson D, Sandlow J.Treatment of varicoceles: techniques and outcomes. Fertil Steril. 2017;108(3):378–84.
27. Beecroft D, JR. Percutaneous varicocele embolization. Can Urol Assoc J J Assoc Urol Can. 2007;1(3):278–80.
28. Nasser HM, Hussein A, Behairy GM, Abdo M. Impact of percu­taneous embolization versus subinguinal microsurgical ligation on semen parameters in primary varicocele patients: comparative study. Egypt J Radiol Nucl Med. 2020;51(1):249.
29. Tiralongo F, Distefano G, Palermo M, Granata A, Giurazza F, Vacirca F, etal. Liquid and solid embolic agents in gonadal veins. J Clin Med. 2021;10(8):1596.
30. Sheehan M, Briody H, O’Neill DC, Bowden D, Davis NF, Given M, etal. Pain relief after varicocele embolization: the patient’s per­spective. J Med Imaging Radiat Oncol. 2020;64(2):215–9.
31. Puche-Sanz I, Flores-Martín JF, Vázquez-Alonso F, Pardo-Moreno PL, Cózar-Olmo JM. Primary treatment of painful varicocoele through percutaneous retrograde embolization with bred coils. Andrology. 2014;2(5):716–20.
32. Cayan S, Shavakhabov S, Kadioğlu A.Treatment of palpable vari­cocele in infertile men: a meta-analysis to dene the best technique. J Androl. 2009;30(1):33–40.
33. Baazeem A, Belzile E, Ciampi A, Dohle G, Jarvi K, Salonia A, etal. Varicocele and male factor infertility treatment: a new meta­analysis and review of the role of varicocele repair. Eur Urol. 2011;60(4):796–808.
34. Jargiello T, Drelich-Zbroja A, Falkowski A, Sojka M, Pyra K, Szczerbo-Trojanowska M. Endovascular transcatheter emboliza­tion of recurrent postsurgical varicocele: anatomic reasons for sur­gical failure. Acta Radiol Stockh Swed 1987. 2015;56(1):63–9.
35. Basile A, Failla G, Gozzo C.Pelvic congestion syndrome. Semin Ultrasound CT MRI. 2021;42(1):3–12.
36. Bookwalter CA, VanBuren WM, Neisen MJ, Bjarnason H.Imaging appearance and nonsurgical management of pelvic venous conges­tion syndrome. Radiographics. 2019;39(2):596–608.
37. Senechal Q, Echegut P, Bravetti M, Florin M, Jarboui L, Bouaboua M, et al. Endovascular treatment of pelvic congestion syn­drome: visual analog scale follow-up. Front Cardiovasc Med. 2021;8:751178.
38. Joh M, Grewal S, Gupta R.Ovarian vein embolization: how and when should it be done? Tech Vasc Interv Radiol. 2021;24(1):100732.
39. de Almeida GR, Silvinato A, Simões RS, Buzzini RF, Bernardo WM.Pelvic congestion syndrome– treatment with pelvic varicose veins embolization. Rev Assoc Médica Bras. 2019;65(4):518–23.
40. Pozzi Mucelli F, Pozzi Mucelli RA, Marrocchio C, Tollot S, Cova MA.Endovascular interventional radiology of the urogenital tract. Medicina (Mex). 2021;57(3):278.
41. Philip F, Shishehbor MH. Current state of endovascular treat­ment for vasculogenic erectile dysfunction. Curr Cardiol Rep. 2013;15(5):360.
42. Mihmanli I, Kantarci F.Erectile dysfunction. Semin Ultrasound CT MRI. 2007;28(4):274–86.
43. De Magistris G, Pane F, Giurazza F, Corvino F, Coppola M, Borzelli A, etal. Embolization of high-ow priapism: technical aspects and clinical outcome from a single-center experience. Radiol Med (Torino). 2020;125(3):288–95.
44. Diehm N, Marggi S, Ueki Y, Schumacher D, Keo HH, Regli C, etal. Endovascular therapy for erectile dysfunction—who benets Most? Insights from a single-center experience. J Endovasc Ther. 2019;26(2):181–90.
45. Wang T-D, Lee W-J, Yang S-C, Lin P-C, Tai H-C, Liu S-P, etal. Clinical and imaging outcomes up to 1 year following balloon angioplasty for isolated penile artery Stenoses in patients with erectile dysfunction: the PERFECT-2 study. J Endovasc Ther. 2016;23(6):867–77.
46. Piegza M, Paterak M, Błachut M, Piegza J. MODERN ENDOVASCULAR TREATMENT METHODS FOR ERECTILE DYSFUNCTION: A CRITICAL ANALYSIS. Wiad Lek. 2020;73(9):2049–55.
47. Sadeghi-Nejad H, Dogra V, Seftel AD, Mohamed MA. Priapism. Radiol Clin North Am. 2004;42(2):427–43.
Interventions oftheExtremity Arteries
MansiVerma andNirajNirmalPandey
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 modication, 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 supercial femoral artery SFA and popliteal artery (<10cm) balloon angioplasty rst is appropriate; however, in cases of stenosis, >10cm 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 ofLower 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 supercial epigastric artery, external pudendal artery, and supercial circumex artery. The CFA bifurcates into supercial femoral and deep femo­ral artery or profunda femoris artery. The profundal femoris artery gives rise to medial and lateral circumex 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 tibiobular 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 classica­tion schemes have been developed for PAD with stratica­tion based on clinical presentation, anatomic distribution, or a combination of clinical factors.
26.2.2 Classication Systems
26.2.2.1 Clinical Classication
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 Classication
This classication 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 >200m Stage IIB Claudication distance <200m Stage III Rest pain Stage IV Ischemic ulcer/gangrene
26.2.3 Rutherford Classication forChronic 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 Classication
Trans-Atlantic Inter-Society Consensus Document II (TASC II)
Fourteen societies from North America and Europe in 2000 formed a consensus regarding the classication 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 reclassication 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 classication.
26.2.5 Diagnostic andImaging 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 conrm 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 oftheExtremity 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 calcied 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 Modication, andSupervised 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 <70mg/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 ofRevascularization
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 calcication.
26.3 Endovascular Revascularization:
Angioplasty andStenting
26.3.1 Evidence-Based Guidelines
forPeripheral 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 (<10cm), balloon angioplasty rst is appropriate; however,
in cases of stenosis >10cm 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-specic factors that predict adverse outcomes after endovascular revascularization. Patient-specic 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 calcica­tion or thrombus, multiple lesions, status of inow 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. 75mg 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 oftheExtremity 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 ofAngioplasty inPeripheral
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 congura­tion, severe calcication, 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 sig­nicance can be determined by hemodynamic gradient mea­surements or diameter reduction measurement. Generally, resting mean trans-lesional gradient >5mm Hg or systolic gradient >10mm Hg is considered signicant.
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 conrmed with contrast injec­tion and uoroscopic landmarks. The balloon pressure is slowly increased using insufator, and ination for approxi­mately 1 minute is performed at the nominal pressure. Nominal pressure is dened as the pressure at which the bal­loon is inated 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 ination. Ination at high pressures may be required in recurrent, residual, and heavily calcied lesions. Resolution of waist denotes ade­quacy of dilatation. After deation and removal of balloon, completion angiogram including distal runoff should be
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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 ofAngioplasty
Imaging: Residual stenosis less than 30%
Hemodynamic: Reduction in the pressure gradient to less
than 5mm Hg mean or 10mm 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 inated 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 >5mm) 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 sufcient 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 inating 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 difcult 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 calcied 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 signicant 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 oftheExtremity Arteries
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Fig. 26.7 A 56-year-old man with intermittent claudication in left leg. Digital subtraction angiography revealed (a) diffuse signicant stenosis with lling defects suggestive of thrombus involving supercial femo-
tic memory that precludes their use in areas with external forces.
Stent grafts (covered stents) are composed of synthetic material such as polytetrauoroethylene (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 (75mg aspirin and 75mg clopidogrel) for 1 month followed by aspirin lifelong. Smoking cessation, blood pressure control, and lipid optimi­zation should be aggressively followed.
26.4 Technical andClinical 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 signicant 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 5years, 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].
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Femoropopliteal Segment In a meta-analysis of endovas­cular versus surgical reconstruction, the primary patency at 1year in surgical group was 72% versus 62% in endovascu­lar group. There was no signicant difference in terms of patency at 4years 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 36months [27]. Schillinger et al.’s RESILIENT trial and DURABILITY study [2325]. 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 signicant 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).
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Fig. 26.8 A 57-year-old man presented with rest pain and ischemic ulcer in right foot. Digital subtraction angiogram (a) revealed diffuse signicant disease in right posterior tibial artery (PTA). Angioplasty of
right PTA was performed (b, c) followed by bioresorbable stent place-
ment in distal PTA