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R Lr=
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η
π
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exiting at the proximal end of the catheter. Therefore, the
proximal hub of the balloon catheter has two ports, one for
the wire and one for the ination of the balloon. The OTW
conguration offers good support, translated into good pushability and trackability, but requires a long guidewire for the
exchange of the balloon catheter, calculated as at least the
distance between the vascular access point and the lesion
plus the length of the balloon catheter. OTW balloon catheters are the most commonly used catheters in peripheral
endovascular interventions.
In the monorail, RX or SOE balloon catheters, the guidewire enters at the distal end of the balloon and has a short
coaxial route within the catheter exiting about 20-25 cm
proximally to the balloon instead of the end of the catheter.
The remaining part of the balloon catheter has only one
lumen and the proximal hub only one port, for the ination
of the balloon. This design requires shorter guidewires,
offers easier catheter exchange by a single operator and has
a lower prole. On the other hand, it offers less pushability
and trackability. RX balloon cathes are most commonly used
for small diameter arteries such as the coronary and the tibial
arteries, or when the crossing prole is of utmost importance, such as in the carotid arteries.
The Balloon
Prole
The crossing prole of a balloon catheter is dened as the
maximum diameter of the balloon region of the catheter. At
this point, the thickness of the folded balloon is added to the
diameter of the inner tube of the shaft which denes the
guidewire lumen. Consequently, balloon catheters supported
by 0.014-inch guidewires have a lower crossing prole than
balloon catheters with 0.035-inch guidewire design. Lower
crossing proles allow easier passage though tight stenoses
and occlusions and require sheaths or guiding catheters of
lower diameter as well.
Ination andDeation Time
The ination and deation time of the balloon is directly proportional to the resistance (R) of the ination tube of the
catheter shaft, which, according to Poiseuille’s law, is
directly proportional to the length (L) of the shaft and the
viscosity (η) of the mixture of saline and contract medium,
and inversely proportional to the radius (r) of the ination
tube to the fourth power:
8
/
Therefore, the radius of the ination tube represents the
major determinant of the ination and deation time. An
ination tube of small diameter secures a low crossing prole of the balloon catheter, but this comes at the cost of lon-
ger ination and deation times. The viscosity of the liquid,
on the other hand, is dened by the ratio of saline and contrast medium. More contrast medium leads to better visibility of the inated balloon but, again, this comes at a cost of
longer ination and deation times.
Compliance
Compliance of a balloon is dened as the change in balloon
diameter (Δd) divided by the change in balloon pressure (Δp)
that caused the diameter change:
Non-compliant balloons are typically made of PET (polyethylene terephthalate) or nylon. Inating these balloons
above their nominal pressure (pressure at which the balloon
reaches its nominal diameter) will cause a sharp increase in
the ination pressure with minimal change in the diameter of
the balloon. Thus, the balloon will expand uniformly over its
longitudinal axis exerting high radial force in the stenotic
area and minimal force in the normal artery, proximally and
distally to the lesion. Non-compliant balloons are therefore
preferable for angioplasties of stenotic lesions.
Compliant balloons are typically made of polyolen
copolymer (POC), polyethylene, polyurethane or silicone.
These balloons are inated by volume instead of pressure,
meaning that continuing ination will cause expansion of the
balloon with a relatively small increase in the ination pressure. The balloon will expand in the direction of least resistance which, in the case of a stenotic lesion, means that the
balloon will acquire a dog-bone shape causing deformation
and stress injury to the adjacent normal artery. Their conformability, on the other hand, makes them ideal for temporary occlusion of large vessels or to expand vascular
prostheses, securing apposition of the graft fabric and the
arterial wall.
Trackability, Pushability, andCrossability
Trackability is the ability of the balloon catheter to be
advanced to the target lesion through the tortuous vessel
anatomy. It depends on several factors, including the exibility and the prole of the balloon catheter, as well as the friction between the balloon catheter and the guiding catheter on
the outside and the guide-wire on the inside.
Pushability is the ability of the balloon catheter to transmit to its distal tip the force applied to the proximal part of
the catheter. High force transmission means that the operator
can feel the resistance at the catheter tip which allows him/
her to adjust the pushing force he/she applies so that crossing
of the lesion is achieved without the risk of vessel injury. A
low balloon catheter prole with a high axial stiffness and
hydrophilic coating contribute to a high pushability.
Crossability is the ability of the balloon catheter to pass
through the lesion. Factors affecting crossability include the
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design of the catheter tip, the crossing prole, the way the
balloon is folded, the hydrophilic coating and the kink resistance of the catheter.
Technique
Vascular Access
Prerequisites for using an artery as an access point to the
arterial system include the relatively supercial position of
the artery, so that it will be easily palpated and punctured, the
presence of a bone behind the artery, so that it will be easily
pressed at the end of the procedure, and the relatively large
calibre of the artery, so that the required sheath will be safely
inserted. The most commonly used artery, fullling all these
conditions, is the common femoral artery (ipsilateral or contralateral to the lesion), whereas the brachial, axillary, radial,
popliteal and even the anterior and posterior tibial arteries
can also be used. The selection of the appropriate access site
for each procedure among the aforementioned options is
based on its proximity to the lesion, the calibre of the sheath
to be used and the availability of the access artery, which
depends on the patency of the artery and the condition of the
overlying skin.
Retrograde Femoral Access
The retrograde femoral access is the most common approach
for angioplasty of the ipsilateral common and external iliac
artery, the carotids and the renal arteries, whereas it can also
be used for angioplasties of the contralateral limb. Advantages
of the common femoral artery (CFA), as an access point,
include the supercial position, the large calibre, the presence of the femoral head behind it, the proximity to most
vascular lesions and the abundant working space over the
legs of the patient.
The puncture site should be above the femoral bifurcation, which is located approximately at the level of the lower
border of the femoral head, and below the inguinal ligament,
which is located approximately at the level of the upper border of the femoral head. Puncture above the inguinal ligament carries the risk of retroperitoneal haemorrhage, since
the artery goes deep in the pelvis and without an osseous
structure behind it to allow manual compression. Puncture of
the supercial femoral artery, on the other hand, carries the
risk of vascular complications such as acute occlusion, arteriovenous stula and pseudoaneurysm, since the origin of
the supercial femoral artery is frequently calcied, has a
smaller diameter, the femoral vein lies behind it, so that both
the artery and the vein can be simultaneously punctured, and
there is no bone behind them to allow manual compression.
Previous open surgery on the CFA may make advancement of the sheath difcult through the scar tissue. Useful
tricks to overcome this difculty include the use of a stiff
wire, instead of the standard one, as well as the pass of sheath
dilators of progressively larger diameter to create a track
through the scar tissue. The scar tissue, on the other hand
will prevent the formation of post-procedural hematomas.
A frequent problem encountered in retrograde punctures
of the CFA is that, in the case of severe stenoses or occlusions of the ipsilateral common or external iliac arteries, the
femoral pulse will be weak or absent. Anatomic landmarks
(puncture at the midpoint of the inguinal ligament, which
extends between the anterior superior iliac spine and the
pubic tubercle) as well as radiographic landmarks (puncture
1cm lateral to the most medial cortex of the femoral head or
puncture of a radiographically visible calcied artery) could
be used, although the most accurate method is undoubtedly
the catheterization of the CFA under ultrasonographic
guidance.
Antegrade Femoral Access
Antegrade femoral access offers the shortest way to the ipsilateral supercial femoral, the popliteal and the infragenicular arteries. On the other hand, antegrade catheterization of
the CFA is more difcult especially in obese patients where
an assistant should retract the abdomen out of the way.
Failure to puncture the CFA proximal enough to its bifurcation may lead to passage of the entry guidewire into the deep
femoral artery. In such a situation, a catheter with a short,
angulated tip could be advanced into the deep femoral artery
and then slowly withdrawn, with continuous injection of
contrast media under oblique uoroscopy, until its tip faces
the supercial femoral artery (SFA). A guidewire could then
be advanced into the SFA.
Retrograde Popliteal Access
The patient is placed in a prone position and the popliteal
artery is punctured under ultrasonographic guidance. Care
should be taken to avoid simultaneous puncture of the overlying popliteal vein. Retrograde popliteal access allows
simultaneous angioplasty of tandem lesions in the iliac arteries and the SFA, angioplasty of lesions in the CFA and ush
occlusions of the SFA.It is also indicated in cases of difcult
or failed attempts to catheterize the CFA. The main disadvantage of the popliteal approach is that the prone position
may not be well tolerated by obese patients.
Retrograde Tibial Access
The anterior and posterior tibial arteries can be cannulated
using a micropuncture kit under ultrasonographic or uoroscopic guidance. The most common indication is the recanalization of chronic total occlusive lesions with simultaneous
antegrade and retrograde subintimal angioplasty when reentry cannot be achieved by the antegrade approach.
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Upper extremity Artery Access
Angioplasty through the upper extremity arteries offers the
advantage of immediate mobilization of the patient as well
as easier advancement of balloons and stents in arteries originating from the aorta at an acute angle, such as the superior
mesenteric artery. Disadvantages include the smaller diameter of these arteries compared to the CFA, as well as their
close proximity with nerves, such as the median nerve in the
case of the brachial artery or the brachial plexus in the case
of the axillary artery. Direct nerve injury or, more frequently,
pressure by a hematoma may result in peripheral
paresthesia.
Lesion Crossing
Crossing of the lesion with a wire is the most critical part of
the procedure. A 0.035-inch, straight or angled, oppytipped, hydrophilic coated guidewire supported by an angled
diagnostic catheter is most commonly used. Smaller diameter guidewires such as 0.014″ or 0.018″ can also be used,
especially in tight stenoses or occlusions or in smaller diameter arteries. Apart from offering support, the catheter adds
steerability, whereas specic catheter shapes can be used to
steer the guidewire into specic arteries.
The lesion is crossed carefully under uoroscopic guidance so that the wire will not be advanced into a dissection
plane inadvertently. If this happens, there are two options.
The guidewire can be withdrawn and another attempt to
cross the lesion transluminally can be made or the guidewire can be advanced past the lesion in the subintimal plane
and re-entry into the lumen be attempted at the other end of
the lesion. Once the lesion is crossed, either transluminally
or subintimally, the hydrophilic guidewire may be
exchanged with a stiffer one to provide better support. It is
of utmost importance that, once the guidewire is in place,
extreme care is taken to maintain the guidewire position
during subsequent exchanges of catheters, balloons and
stents.
• the shaft length is selected based on the distance between
the access point and the lesion.
Under uoroscopic guidance, the balloon is advanced
across the lesion. Correct positioning is achieved by uoroscopic reference to anatomic structures, by road mapping, or
by markers placed on the screen by the operator at the time
of the diagnostic angiography. The balloon is inated to the
rated nominal pressure using an ination device loaded with
dilute contrast (30–50% contrast in saline). Air should be
removed from both the ination device and the balloon and
the ination should be performed with the ination device
facing downwards to prevent air from entering the balloon.
Apart from reducing the visibility of the inated balloon, this
would also carry the risk of infusion of air within the arteries
in case of balloon rupture. As the balloon is inated under
uoroscopic guidance, a waist is seen at the point of maximum stenosis, which usually resolves with further ination
of the balloon. This is an indication for the adequacy of the
angioplasty. The optimal ination time has not been determined and depends on the interventionalist’s preference and
the type of the lesion. An ination of up to 60s may be adequate for most atherosclerotic lesions, whereas several inations of a few minutes each may be necessary for intimal
hyperplasia and recurrent lesions. After deation and withdrawal of the balloon, an angiogram is performed to verify
the adequacy of the result. In cases of residual stenosis or
dissection, reination of the balloon for a longer time may be
performed and if this fails to address the problem, stenting
may be considered.
Pain during balloon ination, attributed to stretching of
the adventitia, is common and could be considered as a sign
of sufcient arterial dilation. The pain should resolve upon
deation of the balloon. Continued pain could be a sign of
arterial rupture and should prompt immediate angiography.
The possibility of rupture or dissection underscores the
importance of the maintenance of the guidewire position
across the lesion until completion angiography has been
performed.
Balloon Angioplasty
The balloon catheter is selected based on the following
factors:
• the balloon diameter should be slightly larger than the
diameter of the target artery, except for severely calcied
lesions where a more conservative approach may be
selected to avoid artery rupture,
• the balloon length should be slightly longer that the lesion
length, so that it does not cause injury to the adjacent normal artery, proximally and distally to the lesion,
Complications
Access Site Complications
Hematoma
Hematoma at the vascular access site represents the most
common complication of percutaneous angioplasty procedures, occurring in up to 9% of the cases [8]. Risk factors for
this complication can be divided into patient-related and
operator-dependent. Patient-related risk factors include
increasing age, female gender, extremes in weight, use of
antiplatelets or anticoagulants, renal failure and other comor-
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bidities such as diabetes, peripheral artery disease, hyperlipidemia, hypertension and NewYork Heart Association class
III or IV heart failure [9]. Operator-dependent risk factors
include the access technique, multiple puncture attempts,
posterior vessel wall puncture, the size of the sheath, the use
of thrombolysis, the use of vascular closure devices, and
post-procedure manual compression [8]. Ultrasound-guided
access appears to be the safest technique, allowing the operator to directly locate the CFA and identify the healthier spot
for needle puncture, avoiding calcied plaques, back wall
injury and inadvertent puncture of adjacent veins.
Hematomas are usually small and cause limited patient
discomfort. Large hematomas, however, can cause nerve
compression, especially in cases of upper extremity access,
deep vein thrombosis, due to compression of the adjacent
vein, and even compartment syndrome. In cases of high
puncture at the groin, above the inguinal ligament, bleeding
control by manual compression may be impossible, leading
to retroperitoneal haemorrhage. Retroperitoneal haemorrhage is a life-threatening complication as it does not present with overt bleeding and may not be diagnosed until the
patient develops abdominal or back pain, hypotension and
tachycardia. Diagnosis is conrmed by computed tomography angiography which, apart from the presence of the retroperitoneal hematoma, will disclose whether there is
active bleeding from the distal external iliac artery. In such
cases bleeding control can be achieved by either open surgical repair or by the endovascular placement of a covered
stent.
Pseudoaneurysm
Pseudoaneurysms at the vascular access site represent the
second most common complication, developing in 0.9–4.9%
of percutaneous angioplasty procedures [10]. The risk factors are similar to those for hematoma, with a large sheath
size, inadequate compression, puncture of the deep femoral
artery and the use of antiplatelets or anticoagulants being the
most common.
The clinical presentation of pseudoaneurysms is also similar to that of a hematoma, with small pseudoaneurysms
causing minimal discomfort, whereas large pseudoaneurysms may cause compression symptoms to the adjacent
structures, including veins, nerves and the skin. Differential
diagnosis between a hematoma and a pseudoaneurysm is
made by palpation, revealing a pulsatile mass in the case of a
pseudoaneurysm, and by auscultation, revealing a systolic
bruit. The diagnosis is conrmed by duplex ultrasound,
revealing a characteristic turbulent ow within the aneurysm
(the yin yang sign) and an equally characteristic “to and fro”
ow at the pseudoaneurysm neck (Fig.9.1).
The treatment of choice is ultrasound-guided thrombin
injection, with open surgical repair reserved for pseudoaneurysms in which thrombin injection is contraindicated, namely
pseudoaneurysms with a neck diameter of >3 mm, which
increases the risk of distal embolization in case of thrombin
injection, or with concomitant arteriovenous stula, which
poses the risk of pulmonary embolism. Ultrasound-guided
manual compression can also be attempted but is time consuming, painful for the patient and labour-intensive for the
Fig. 9.1 Duplex ultrasound of a pseudoaneurysm of the common femoral artery, revealing a characteristic turbulent ow within the aneurysm (the
yin yang sign) and a “to and fro” ow at the pseudoaneurysm neck
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operator. The need for the ultrasound during manual compression is to help in the regulation of the amount of downward
force applied on the pseudoaneurysm, which should be high
enough to interrupt ow within the pseudoaneurysm but not
that high to stop ow in the underlying artery. The success rate
of ultrasound-guided manual compression is reported to range
between 60 and 95% [11], whereas the success rate of ultrasound-guided thrombin injection exceeds 95% [10].
Arteriovenous Fistula
Arteriovenous stulas at the vascular access site occur in
0.25–2.8% of percutaneous angioplasty procedures [12].
They occur due to a simultaneous puncture of an artery and
a vein by the access needle. Since the common femoral
artery and the common femoral vein lie side by side, it is
impossible to puncture both vessels simultaneously.
Arteriovenous stulas usually occur between the supercial
femoral or deep femoral artery and the corresponding veins
or the common femoral vein. However, an arteriovenous stula between the common femoral artery and the supercial
circumex iliac vein may also occur [12].
Patient-related risk factors include female gender and
hypertension, whereas procedural risk factors include emergency procedures, the use of anticoagulation and a left-sided
puncture [12, 13]. Diagnosis is suspected by clinical examination revealing the presence of a thrill or a bruit and is veried by a colour duplex ultrasound.
Since these stulas occur due to the simultaneous puncture of an artery and a vein by an 18G needle, the outer diameter of which is 1.27mm, they are usually small in size and
rarely symptomatic. Moreover, the natural history of arteriovenous stulas is usually benign, resulting in spontaneous
resolution in 38–81% of the cases by 2–12months [13, 14].
Symptoms may be arterial (limb ischemia), venous (limb
oedema) or cardiac (high output heart failure). In such cases,
closure of the arteriovenous stula will be needed, usually by
open surgery or by a covered stent in appropriately selected
cases [15].
Access Site Thrombosis
Access site thrombosis is rare, occurring in less than 0.3% of
peripheral angioplasty procedures [16, 17]. It is most commonly due to local dissection, caused by the puncture of a
heavily calcied common femoral artery. An increased risk
of thrombotic access site complications when closure devices
are used has also been reported [16], but has not been conrmed in a large meta-analysis by the Cochrane Database of
Systematic Reviews [18].
Access site thrombosis will present with acute limb ischemia or with worsening of a preexisting limb ischemia. The
treatment of choice is open surgery (thromboendarterectomy), although an endovascular intervention through a
remote access site is also an option.
Angioplasty Site Complications
Dissection
Dissection may occur during crossing of the lesion with the
wire or during the ination of the balloon. Some degree of
dissection during the ination of the balloon is inevitable
since the arterial wall is stretched whereas the atherosclerotic
plaque cannot. The classication system of the National
Heart, Lung and Blood Institute (NHLBI) for coronary dissections after balloon angioplasty can be adopted for peripheral artery dissections [19]. Dissections in this scheme are
graded based on their angiographic appearances as types A
through F. Type A dissections represent minor radiolucent
areas within the arterial lumen during contrast injection.
Type B dissections are parallel tracts or a double lumen separated by a radiolucent area. In both type A and B dissections,
there is minimal or no persistence of contrast after the dye
has cleared from the lumen. Type C dissections appear as
contrast outside the arterial lumen (“extraluminal cap”) with
persistence of contrast after dye clearance. Type D dissections represent spiral (“barber shop pole”) lling defects,
frequently with excessive contrast staining of the false
lumen. Type E dissections appear as persistent lling defects
within the arterial lumen. Type F dissections represent those
that lead to total occlusion of the artery.
Minor dissections that are non-obstructive (types A and
B) may be left untreated, whereas ow-limiting dissections
(types C-F) need to be treated, usually by bailout stenting.
Risk factors for severe dissection after balloon angioplasty
of the supercial femoral artery include a vessel diameter<5mm, lesion length>15cm, and occlusion or degree
of stenosis ≥70% [20, 21], whereas a prolonged balloon
ination time (>3min) and the use of long balloons appear to
be protective [22, 23].
The reported incidence of ow-limiting dissections after
femoropopliteal balloon angioplasty ranges widely between
7.4 and 53% [24, 25]. Apart from being an obvious cause of
procedural failure, ow-limiting dissections are associated
with a signicantly higher restenosis and target lesion revascularization rate [20, 26].
Distal Embolization
Distal embolization is a limb threatening complication of
balloon angioplasty of the peripheral arteries. The incidence
is reported to be less than 5%, when clinical and angiographic criteria are used for the diagnosis, although embolic
signals by Doppler ultrasound are detected in all patients
during both wire crossing and angioplasty [27, 28]. Risk factors include the presence of thrombus, TASC-D lesions and
prior history of amputation [28]. Distal protection with a lter basket has been proposed as a preventive measure, but its
cost-effectiveness remains to be proven. Therapeutic options
include aspiration thrombectomy, mechanical thrombectomy
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and catheter-directed thrombolysis, whereas surgical thrombectomy may be needed when the aforementioned endovascular means have failed to restore patency.
Arterial Rupture
Arterial rupture during balloon angioplasty is a lifethreatening complication, occurring in less than 1% of
cases. Acute pain, that does not resolve after balloon deation, and hypotension raise the suspicion of arterial rupture,
the diagnosis of which is veried by immediate angiography showing contrast medium extravasation. Risk factors
include the use of an oversized or a cutting balloon and
recanalization of occlusions and high-grade stenoses in
heavily calcied arteries [29, 30]. The external iliac artery
appears to be the most susceptible to rupture [30]. Treatment
consists of reinating the balloon to about 1atm across the
rupture to achieve temporary hemostasis. This will give us
Fig. 9.2 (a) Diagnostic
angiography conrming the
presence of a 6cm in length
occlusion of the SFA at the
adductor canal, (b) crossing
of the lesion with a 0.035inch angled, oppy-tipped,
hydrophilic coated guidewire
supported by an angled
diagnostic catheter, (c)
injection of contrast medium
veries the intraluminal
position of the wire and
catheter after crossing of the
lesion, (d) and (e) balloon
angioplasty with a 6mm in
diameter and 15cm in length
balloon, (f) completion
angiography conrming the
re-established SFA patency
abc
enough time to select the appropriate stent-graft, unpack,
ush and place it so that denitive control of bleeding is
achieved. Surgical repair is reserved for cases where the
implantation of a covered-stent is impossible or has failed
to seal the bleeding.
Case Presentation
Continued from page 73
The patient was taken to the angiographic suite and placed
in a supine position on the interventional table. Under local
anaesthesia and ultrasonographic guidance an antegrade
femoral access was obtained and a 5F sheath was inserted.
Diagnostic angiography demonstrated the presence of atherosclerotic disease, causing moderate stenosis in the proximal two thirds of the SFA and a 6cm in length occlusion of
the SFA at the adductor canal (Fig. 9.2). The lesion was
crossed with a 0.035-inch angled, oppy-tipped, hydrophilic
def
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I. D. Kakisis
coated guidewire supported by an angled diagnostic catheter.
After crossing of the lesion, the catheter was advanced to the
popliteal artery and the wire was removed. Injection of contrast medium veried the intraluminal position of the catheter. The wire was advanced again through the catheter, the
catheter was removed and balloon angioplasty of the whole
length of the SFA followed with a 6 mm in diameter and
15cm in length balloon. Completion angiography conrmed
the unrestricted patency of the SFA and the absence of distal
embolization.
The patient reported immediate pain relief. On physical
examination, the pink colour of the foot was restored, the
capillary rell time was less than a second and there were
palpable pulses in the popliteal artery.
The patient was placed on best medical therapy, including
clopidogrel, blood pressure and lipid control. He was referred
to the smoking cessation clinic and was advised to walk for
at least 30min every day. He was discharged on the following day.
References
1. Fogarty TJ, Cranley JJ, Krause RJ, Strasser ES, Hafner CD. A
method for extraction of arterial emboli and thrombi. Surg Gynecol
Obstet. 1963;116:241–4.
2. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technic and a preliminary
report of its application. Circulation. 1964;30:654–70. https://doi.
org/10.1161/01.cir.30.5.654.
3. Grüntzig A, Hopff H.Perkutane Rekanalisation chronischer arterieller Verschlüsse mit einem neuen Dilatationskatheter. Modikation
der Dotter-Technik. Dtsch Med Wochenschr. 1974;6(99):2502–11.
https://doi.org/10.1055/s- 0028- 1108161.
4. The SH, Gussenhoven EJ, Zhong Y, Li W, van Egmond F, Pieterman
H, van Urk H, Gerritsen GP, Borst C, Wilson RA, etal. Effect of
balloon angioplasty on femoral artery evaluated with intravascular ultrasound imaging. Circulation. 1992;86:483–93. https://doi.
org/10.1161/01.cir.86.2.483. PMID: 1386293.
5. Castaneda-Zuniga WR, Formanek A, Tadavarthy M, Vlodaver Z,
Edwards JE, Zollikofer C, Amplatz K.The mechanism of balloon
angioplasty. Radiology. 1980;135:565–71. https://doi.org/10.1148/
radiology.135.3.7384437. PMID: 7384437
6. Schmidt W, Schmitz KP.Devices. In: Lanzer P, editor. Mastering
endovascular techniques: a guide to excellence. Philadelphia:
Lippincott Williams & Wilkins; 2007. p.114–35.
7. Sullivan TM, Rizvi AZ.Technique: endovascular therapeutic. In:
Cronenwett JL, Johnston KW, editors. Rutherford’s vascular surgery. 16th ed. Philadelphia, PA: Elsevier; 2014. p.1322–37.
8. Sambol E, McKinsey. Local complications: endovascular. In:
Cronenwett JL, Johnston KW, editors. Rutherford’s vascular surgery. 16th ed. Philadelphia, PA: Elsevier; 2014. p.704–22.
9. Sobolev M, Slovut DP, Lee Chang A, Shiloh AL, Eisen
LA.Ultrasound-guided catheterization of the femoral artery: a systematic review and meta-analysis of randomized controlled trials. J
Invasive Cardiol. 2015;27:318–23. PMID: 26136279.
10. Delf J, Ramachandran S, Mustafa S, Saeed A, Kandiyil N.Factors
associated with pseudoaneurysm development and necessity for
reintervention: a single centre study. Br J Radiol. 2019;92:20180893.
https://doi.org/10.1259/bjr.20180893. PMID: 30982331; PMCID:
PMC6592087.
11. Lange P, Houe T, Helgstrand UJ. The efcacy of ultrasoundguided compression of iatrogenic femoral pseudo-aneurysms. Eur
J Vasc Endovasc Surg. 2001;21:248–50. https://doi.org/10.1053/
ejvs.2001.1325. PMID: 11352684.
12. Middleton WD, Robinson KA. Analysis and classication of
postcatheterization femoral arteriovenous stulas based on color
Doppler examinations. J Ultrasound Med. 2022;41:207–16. https://
doi.org/10.1002/jum.15696. PMID: 33720458.
13. Kelm M, Perings SM, Jax T, Lauer T, Schoebel FC, Heintzen MP,
Perings C, Strauer BE. Incidence and clinical outcome of iatrogenic femoral arteriovenous stulas: implications for risk stratication and treatment. J Am Coll Cardiol. 2002;40:291–7. https://doi.
org/10.1016/s0735- 1097(02)01966- 6. PMID: 12106934.
14. Toursarkissian B, Allen BT, Petrinec D, Thompson RW, Rubin
BG, Reilly JM, Anderson CB, Flye MW, Sicard GA.Spontaneous
closure of selected iatrogenic pseudoaneurysms and arteriovenous
stulae. J Vasc Surg. 1997;25:803–9. https://doi.org/10.1016/
s0741- 5214(97)70209- x. PMID: 9152307.
15. Zilinyi RS, Sethi SS, Parikh MA, Parikh SA.Iatrogenic arteriovenous stula following femoral access precipitating high-output heart
failure. JACC Case Rep. 2021;3:421–4. https://doi.org/10.1016/j.
jaccas.2020.12.031. PMID: 34317549; PMCID: PMC8311044.
16. Noori VJ, Eldrup-Jørgensen J. A systematic review of vascular
closure devices for femoral artery puncture sites. J Vasc Surg.
2018;68:887–99. https://doi.org/10.1016/j.jvs.2018.05.019.
17. Ramirez JL, Zarkowsky DS, Sorrentino TA, Hicks CW, Vartanian
SM, Gasper WJ, Conte MS, Iannuzzi JC. Antegrade common
femoral artery closure device use is associated with decreased
complications. J Vasc Surg. 2020;72:1610–1617.e1. https://doi.
org/10.1016/j.jvs.2020.01.052.
18. Robertson L, Andras A, Colgan F, Jackson R. Vascular closure devices for femoral arterial puncture site haemostasis.
Cochrane Database Syst Rev. 2016;3:CD009541. https://doi.
org/10.1002/14651858.CD009541.pub2. PMID: 26948236
19. Rogers JH, Lasala JM. Coronary artery dissection and perforation complicating percutaneous coronary intervention. J Invasive
Cardiol. 2004;16:493–9. PMID: 15353832.
20. Fujihara M, Takahara M, Sasaki S, Nanto K, Utsunomiya M,
Iida O, Yokoi Y. Angiographic dissection patterns and patency
outcomes after balloon angioplasty for supercial femoral
artery disease. J Endovasc Ther. 2017;24:367–75. https://doi.
org/10.1177/1526602817698634.
21. Hong H, Park UJ, Roh YN, Kim HT.Predictive factors of severe
dissection after balloon angioplasty for femoropopliteal artery disease. Ann Vasc Surg. 2021;77:109–15. https://doi.org/10.1016/j.
avsg.2021.05.048. PMID: 34428439.
22. Horie K, Tanaka A, Taguri M, Kato S, Inoue N. Impact of prolonged ination times during plain balloon angioplasty on angiographic dissection in femoropopliteal lesions. J Endovasc Ther.
2018;25:683–91. https://doi.org/10.1177/1526602818799733.
PMID: 30203701.
23. Tan M, Urasawa K, Koshida R, Haraguchi T, Kitani S, Igarashi Y,
Sato K. Comparison of angiographic dissection patterns caused
by long vs short balloons during balloon angioplasty of chronic
Femoropopliteal occlusions. J Endovasc Ther. 2018;25:192–200.
https://doi.org/10.1177/1526602818756610. PMID: 29429382.
24. Fanelli F, Cannavale A, Boatta E, Corona M, Lucatelli P, Wlderk
A, Cirelli C, Salvatori FM.Lower limb multilevel treatment with
drug-eluting balloons: 6-month results from the DEBELLUM
randomized trial. J Endovasc Ther. 2012;19:571–80. https://doi.
org/10.1583/JEVT- 12- 3926MR.1. PMID: 23046320.
9 Balloons andPercutaneous Transluminal Balloon Angioplasty
https://t.me/medicina_free
81
25. Werk M, Albrecht T, Meyer DR, Ahmed MN, Behne A, Dietz U,
Eschenbach G, Hartmann H, Lange C, Schnorr B, Stiepani H,
Zoccai GB, Hänninen EL.Paclitaxel-coated balloons reduce restenosis after femoro-popliteal angioplasty: evidence from the randomized PACIFIER trial. Circ Cardiovasc Interv. 2012;5:831–40.
https://doi.org/10.1161/CIRCINTERVENTIONS.112.971630.
PMID: 23192918.
26. Kobayashi N, Hirano K, Yamawaki M, Araki M, Sakai T, Sakamoto
Y, Mori S, Tsutsumi M, Honda Y, Ito Y. Simple classication and
clinical outcomes of angiographic dissection after balloon angioplasty for femoropopliteal disease. J Vasc Surg. 2018;67(4):1151–
8. https://doi.org/10.1016/j.jvs.2017.08.092. PMID: 29242063.
27. Lam RC, Shah S, Faries PL, McKinsey JF, Kent KC, Morrissey
NJ.Incidence and clinical signicance of distal embolization during percutaneous interventions involving the supercial femoral
artery. J Vasc Surg. 2007;46(6):1155–9. https://doi.org/10.1016/j.
jvs.2007.07.058. PMID: 18154991.
28. Shammas NW, Shammas GA, Dippel EJ, Jerin M, Shammas
WJ. Predictors of distal embolization in peripheral percutaneous
interventions: a report from a large peripheral vascular registry. J
Invasive Cardiol. 2009;21:628–31. PMID: 19966364.
29. Sobrinho G, Albino JP.Delayed rupture of the external iliac artery
after balloon angioplasty and stent placement. J Vasc Interv Radiol.
2008;19:460–2. https://doi.org/10.1016/j.jvir.2007.11.013. PMID:
18295711.
30. Allaire E, Melliere D, Poussier B, Kobeiter H, Desgranges P,
Becquemin JP. Iliac artery rupture during balloon dilatation:
what treatment? Ann Vasc Surg. 2003;17:306–14. https://doi.
org/10.1007/s10016- 001- 0404- 1. PMID: 12712371.
The Specificities oftheCommon
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Femoral Artery Anatomy, Calcification
andTreatment
BahaaNasr andYannGouëc
10
Introduction
The latest advances in percutaneous endovascular management of peripheral artery disease and the recent introduction
of drug-eluting devices have led to a dramatic increase in the
number of patients treated percutaneously [1, 2]. However,
common femoral artery (CFA) bifurcation is a notable exception because of the strategic location of the vessel, the clinical concern for possible stent fracture, and the heavily
eccentric calcied character of the CFA plaques.
Repeated studies have shown good medium-term outcome of endovascular treatment of the CFA bifurcation.
Stricker et al. showed a primary patency rate of 83% at
24months follow up. [3] In a prospective, randomized trial
(TECCO trial), Gouëfc etal. reported a 30-days perioperative morbidity and mortality rate signicantly higher in the
open surgery group [4]. At 2years, there were similar rates
of clinical improvement, primary patency and freedom from
target lesion revascularization in both arms [4].
The aim of this paper is to provide a comprehensive
review of the literature on CFA anatomy and calcications in
relation to endovascular management of the CFA
bifurcation.
CFA Anatomy
The common femoral artery follows the external iliac artery
passing under the inguinal ligament. It then divides into the
deep and supercial femoral arteries. Some physicians consider hip motion a contraindication to stent placement across
B. Nasr
Department of Vascular and Endovascular Surgery, Brest
University Hospital, Brest, France
Y. Gouëfc (*)
Department of Vascular and Endovascular Surgery, Groupe
Hospitalier Paris St Joseph, Paris, France
e-mail: ygouefc@ghpsj.fr
the inguinal ligament for fear of kinking, fracture or development of intimal hyperplasia leading to device occlusion [5–
7]. The CFA is relatively xed between the inguinal ligament
above and the Sartorius muscle below [8]. Lopez etal. found
that the deformation of the CFA is the result of a movement
involving bending and torsion of the axis of the artery at two
different points along its course. These deformations occur
below the inguinal ligament and above the Sartorius muscle
[8]. Tijani etal. analyzed the deformations of the iliofemoral
axis during the movements of exion and of extension of the
hip and evaluated the impact of the implantation of a CFA
stent on the deformations observed [9]. In this study, the
authors performed bilateral angiography to assess the deformities of the external iliac artery, common femoral artery
and femoral bifurcation before and after stent implantation.
They demonstrated that the CFA is a xed segment between
two points of mobility at the junction between the external
iliac artery and the CFA proximally and the junction between
the CFA and its bifurcation distally. The exion of the hip
joint did not reveal new points of deformation in the CFA
segment from the front or the side. As far as, the implantation
of a nitinol self-expandable stent in the CFA did not modify
these observations. These results are consistent with the stent
fractures seen in the various clinical trials. Indeed, stent fractures are often found in endovascular treatment of extensive
lesions between the external iliac and common femoral arteries [4, 10].
The interwoven design of the Supera helical interwoven
nitinol stent (Abbott Vascular, Santa Clara, California)
appears to be an ideal candidate for this location. It has signicantly greater radial strength and crush resistance than
other self-expanding stents, making it theoretically attractive
as a stent of choice for the frequent bending and extrinsic
compression encountered in this vessel segment. This stent
has demonstrated good patency rates associated with reduced
stent fractures in femoropopliteal lesions [11–14]. Given the
signicant differences in stent design and fracture rates
between the newer generations of stents, it is likely that
newer generation stents may be preferred for the treatment of
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_10
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B. Nasr and Y. Gouëc
CFA stenosis. Unfortunately, vascular injury at the distal
ends of the stent caused by hip motion could lead to the
development of neointimal hyperplasia. Drug-eluting selfexpanding stents may offer an advantage through a potential
reduction in restenosis.
Bifurcation lesions are one of the more complex lesion
subgroups that we are confronted with. Treating CFA by
endovascular repair remains challenging, especially when
the lesions are extended to the bifurcation and require complex endovascular technics. CFA bifurcation stenting can
contribute to hemodynamic disturbances and therefore
potential restenosis [15].
Azema etal. classied CFA occlusive lesions into four
groups [10]. Type I represents lesions that are located at
the iliac external artery and are extended to the CFA.Type
II lesions are limited to the CFA. Type III represents
lesions located at the CFA and its bifurcation. Type IV
lesions represent proximal and distal stenosis bypass anastomosis. Rabellino etal. proposed a new classication by
subclassifying type III CFA lesions and adding a new
group including lesions that started at the external iliac
artery extending into CFA and affecting its bifurcation
[16]. The Bifurcation lesions of the CFA could also be
classied according to the Medina classication, a classication developed for coronary arteries that was applied for
the femoral bifurcation [17].
The cornerstone of a successful procedure is to optimally
restore ow in the femoral bifurcation. In a morphological
analysis of the CFA bifurcation, we reported a mean angle
between the supercial femoral artery (SFA) and the deep
femoral artery (DFA) of 28.47° ± 5.51°, a mean angle
between the CFA and the DFA of 149.85°± 9.85°, and a
mean angle between the CFA and the SFA of 167.23°±9.80°
[18]. We have shown a positive correlation between the
bifurcation angle and the diameter of the mother vessel,
meaning that the bifurcation angle is less acute when the
CFA diameter is larger [18]. In these cases, T-stenting is the
appropriate technique because the second stent, implanted
through the struts of the rst stent, completely covers the
ostium of the second branch without covering the ostium of
the main branch. However, the kissing stent technique is ideally performed when the bifurcation angle is acute and when
the proximal CFA is free of disease and there is no need to
deploy a stent proximally. We also found a 25% diameter
reduction between the mother vessel and the larger daughter
vessel. This reduction results in incomplete apposition of the
stent struts, which prevents optimal ow in the CFA bifurcation and may increase in-stent restenosis and occlusion. To
avoid this risk, “Tour Eiffel” technic could be used. Dedicated
stents should be designed with diameter reduction and ow
law in mind to avoid apposition failure between the mother
and daughter vessels and to ensure optimal ow in the daughter vessels.
CFA Calcications
The main problem underlying atherosclerotic disease of the
CFA is the typically high calcium concentration, and the
very challenging endovascular procedures when CFA is
highly calcied. However, little is known about the calcication process at the femoral level. Previous studies have
reported large differences in histomorphological composition with respect to lipids, intraplaque haemorrhage, inammatory cells and calcications. Plaque characteristics depend
on its location in the arterial bed [19, 20]. Vascular calcication begins as microcalcications, which can progress over
time to macrocalcications that can occur as a calcied plate
called sheet calcication, or as osteoid metaplasia [21, 22].
Davaine etal. performed histological analysis to characterize
the cellular populations present in the CFA atherosclerotic
lesions [23]. Forty-three femoral plaques from femoral endarterectomy specimens were analyzed. 65% showed osteoid
metaplasia, which included osteoblasts, osteoclast-like cells
and bone marrow (Fig.10.1). Azeez etal. reported a high
relative amount of nodular calcication in femoral plaques
[24]. The showed that a> 90% stenosed vessels contained
22.4±12.3% of nodular and 14.5±11.8% of sheet calcication [24]. Nodular calcication has been suggested to emerge
by fracture from sheet calcication [25]. This possibly
explains the highest prevalence of nodular calcication in the
CFA, which is subjected to most dynamic movement, in
comparison to more stagnant coronary and carotid arteries.
OM
BM
Fig. 10.1 Magnication of the area of osteoid metaplasia (OM) with
osteocytes (*), and bone marrow (BM) in a common femoral plaque
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