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10 The Specicities oftheCommon Femoral Artery Anatomy, Calcication andTreatment
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CFA calcications will have an impact in the vessel preparation, which is a key step in ensuring good subsequent
treatment. Angioplasty is the most common technique. The
interest of arterial preparation by balloon angioplasty has
been shown by several studies [26, 27]. The randomized
Zilver PTX trial showed a trend towards better patency at
5 years in the drug-eluting-stent (DES) and preparation
group versus the DES without preparation group (72.4 vs
64.9%) [26]. However, balloon angioplasty works by applying constant pressure to supercial soft tissue, which can
lead to excessive force, causing elastic recoil, frequent
dissection and loss of blood ow. Other solutions could be
considered to combat calcication. High-pressure balloons
can be used in addition to simple angioplasty to remove the
most refractory stenoses. Atherectomy devices allow lumen
gain and it is mandatory when using drug-coated devices. As
in open surgery, atherectomy aims to destroy and/or remove
atheromatous plaque. Atherectomy can be directional
(SilverHawk®, TurboHawk®, Hawkone®, Pantheris®),
orbital (Diamondback360 R® Peripheral Orbital
Atherectomy), rotative (Jetstream®, Phoenix®) or laser
(Turbo-Elite® laser atherectomy catheter). Plaque modication could lead to better drug penetration into the arterial
wall and improved drug uptake [28]. For eccentric calcications, the directional atherectomy system is a good indication. However, for circumferential calcied lesions, a
rotational atherectomy system or endovascular lithotripsy
technique is preferred. Debulking may be particularly useful
in the treatment of CFA lesions, given the high rates of osteoid metaplasia observed in the CFA atherosclerotic plaques.
Cioppa et al. reported the outcomes of 30 patients with
severely calcied obstructions of the CFA treated by directional atherectomy and drug-coated balloon [29]. At
12months, they observed a primary patency rate of 93.4%
and a freedom from target lesion revascularization (TLR) of
96.7%. Bailout stenting was needed in 10% of treated cases.
In a retrospective study comparing the directional atherectomy with antirestenotic therapy (DAART) in the form of
DCB vs DCB angioplasty alone, Stavroulakis etal. showed
that CFA preparation with directional atherectomy was not
associated with statistically signicant higher primary
patency or freedom from TLR compared to DCB angioplasty
alone at 12months [30].
Intravascular lithotripsy (IVL®; Shockwave Medical,
Santa Clara, USA) was recently introduced as an endovascular option to treat the typically high calcium burden lesions.
The use of IVL showed promising results in femoropopliteal
and below-the-knee occlusive lesions [31, 32]. This technic
is based on the use of pulsatile sonic pressure waves that
interact with calcium, creating signicant shear stress that
has the ability to fracture the calcium. Brodmann et al.
reported good acute results using the peripheral intravascular
lithotripsy system use in calcied CFA lesions [33]. The
mean diameter stenosis after IVL treatment was 21.3%, corresponding to an acute mean lumen gain of 3.1±1.3mm.
The IVL advantage is that it allows angioplasty to be performed with less pressure, thus avoiding dissection. It also
makes the artery wall more compliant, making it easier to
treat with a DCB or a self-expanding stent. Stavroulakis
etal. analyzed 33 cases of severely calcied CFA atherosclerotic disease treated with intravascular lithotripsy [34]. They
showed the combination of IVL and DCB angioplasty for
calcied CFA disease was associated with low risk for periprocedural complications, acceptable 12months clinical outcomes, and low rates of reinterventions [34].
The CFA Treatment
Percutaneous transluminal angioplasty. After vessel preparation, the treatment is chosen according to the preparation
technique and the operator’s preferences. Percutaneous
transluminal angioplasty (PTA) is the most commonly used
technique in the treatment of femoropopliteal lesions. When
used alone to treat CFA lesions, PTA was associated with a
high rate of provisional stenting for suboptimal angioplasty
results or for bail-out reasons. Bonvini etal. had a 38.1% of
provisional stent placement [6]. At 12months, they described
a restenosis rate of 19.5% and a TLR rate of 14.1%. In a
review of the literature, Wong etal. reported that CFA lesions
treated with PTA alone showed primary patency rates of
59% to 88% at 1year and 83% at 2years [35]. Poorer outcomes of PTA are related to the eccentric calcications of the
CFA lesions, the intimal tears and dissections related to the
high shear forces applied by the high balloon pressures [36].
Drug-coated balloon angioplasty. Drug-coated therapies
have been developed as an attractive alternative for femoropopliteal lesions with the aim of reducing reintervention
rates by preventing restenosis. It has the advantage of vascular intima hyperplasia inhibition without leaving anything
behind. However, as with PTA, DCB do not prevent elastic
recoil and eventually lead to ow-limiting dissections.
Stavroulakis et al. compared the directional atherectomy
with DCB (DAART) vs DCB angioplasty alone in the treatment of CFA occlusive lesions [30]. They treated 47 lesions
(DCB 26 vs DAART 21), with a mean lesion length of
39±14mm for DCB group and 34±16mm for DAART
group. Vessel calcication scores were comparable between
groups. They reported a provisional stenting rate of 3.8% in
the DCB group and 4.7% in the DAART group. The
12-months PP (88% vs 68%) and freedom from TLR (89%
vs 75%) were higher in the DAART group without statistically signicant difference.
Scaffolding strategy. Despite improvements in endovascular techniques and materials, the CFA was widely regarded
as a “no stent zone”. Stenting was reserved for salvaging
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suboptimal angioplasty results in patients who were not candidates for more denitive surgical treatment. Literature
review of CFA lesions treated with stenting showed excellent
mid-term outcomes [3, 4]. In a retrospective study, Stricker
etal. reported the mid-term outcomes of CFA stenting in 27
occlusive lesions [3]. The PP was 87% and 83% at 12 and
24 months. In a single centre retrospective study, Thiney
et al. evaluated the PTA of the CFA lesions [37]. Primary
stenting was performed in 95% of cases. At 2-years, they
reported a PP rate of 92.5%. The prospective randomized
French TECCO trial, which compared CFA stenting with
CFA endarterectomy, showed signicantly lower morbidity
and mortality in the endovascular group (6.4% vs 26%;
p=0.005) [4]. It also showed no difference in PP and reintervention rates at 2years in both arms [4].
The “simple” stenting technique, using a single stent in
the CFA or a single stent between the CFA and one of the
daughter’s arteries, must be distinguished from the “complex” stenting techniques. The choice of technique depends
on the location of the lesion and its classication. Simple
stenting can be used for Azema I and II lesions and in case of
occlusion of one of the daughter arteries (SFA or DFA). We
will describe the different complex stenting techniques used
for Azema III type bifurcation lesions.
The “V” and the “simultaneous kissing stents” technique
(Fig. 10.2). The “V stenting” technique consists of the
implantation of 2 stents together. One stent is advanced into
the DFA, the other into the SFA, and the 2 stents touch each
other forming a proximal carina. When this carina extends
5mm or more into the CFA, this technique is called “kissing
stent”. The most suitable lesions for this technique are ostial
lesions. The stents used in this technique are often balloon
expandable stents. In order to facilitate implantation, it is
preferable to work with two 0.014 guides or to implant the 2
stents simultaneously by performing a retrograde puncture
of the homolateral SFA.The main advantage of this technic
is to never lose the vessel access. As far as, there is no need
to re-cross a stent when a nal kissing ination is performed.
Disadvantages include the difculty of placing another stent
proximally if needed and the gap that may be left between
the kissing stent and the proximal stent.
The “T stenting” technique (Fig. 10.3). This technique
consists of positioning a stent between the CFA and the
DFA.If a balloon stent is used, the POT (Proximal optimization technique) can be performed at the proximal part of the
stent in the CFA.This allows the stent to be applied to the
CFA walls and the stent mesh to be opened at this point. The
guidewire is left in place and a second guidewire is used to
catheterize the SFA through the previous stent struts. The
stent struts are opened by a 4mm balloon allowing the passage and implantation of a second stent at the SFA.A nal
kissing balloon angioplasty allows for proper stent application and remodeling.
B. Nasr and Y. Gouëc
Fig. 10.2 The “V” and the “simultaneous kissing stents” technique
Fig. 10.3 The “T stenting” technique
The “Tour Eiffel” technique (Fig.10.4). This technique
consists of placing a self-expanding stent in the CFA.A kissing angioplasty with two 0.014 balloons is performed at the
10 The Specicities oftheCommon Femoral Artery Anatomy, Calcication andTreatment
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Discussion
CFA endarterectomy was historically recommended as the
standard of care of the CFA occlusive lesions, given its
excellent, durable patency and long-term freedom from
reintervention. However, open surgery is associated with
high rates of morbidity and mortality, particularly in obese
patients and those with other cardiopulmonary morbidities. Studies have reported increased complication rates. In
a large registry, Nguyen et al. reported a morbidity and
mortality rate of 15%, including a death rate of 3.4% [42].
In a randomized trial comparing surgery with bioresorbable stents, Linni etal. observed a surgical site infection
rate of 18% [43]. Endovascular treatment of CFA has
emerged as an alternative to open surgery with a low rate
of local and overall complications as a major advantage
[4]. The specicities of the CFA are its anatomy and the
bulky, eccentric calcications. As far as, femoral bifurcation involvement is common, with disease extending into
the proximal DFA and SFA.In a retrospective observational study describing the morphology and the composition of CFA lesions, Kaneta et al. showed that 65% of
lesions were Azema III lesions [44]. In terms of calcication, a total 33% CFAs had a calcium burden greater than
1.1cm3, which was identied as a potential threshold for
the need to stent the lesion [44].
An analysis based on the TECCO trial comparing clini-
Fig. 10.4 The “Tour Eiffel” technique
ostium of both daughter arteries, extending into the existing
self-expanding stent. Finally, a kissing stent is made at the
level of the daughter arteries. The kissing stent can be made
with two balloon stents, which protrude very slightly into the
self-expanding stent.
Despite the anatomical location of the CFA and concerns
about mechanical stress during hip exion, several studies have
shown a low rate of stent fracture of less than 3% [3, 37, 38].
However, the main limitation is that stenting of the CFA may
preclude an important access site for percutaneous procedures.
Despite these limitations, stenting with new generation devices
with increased exibility and radial force may be a treatment
option in highly selected patients and in severely calcied
lesions. The Supera™ stent (Abott Vascular Inc., Santa Clara,
CA, USA) has shown very good results in CFA treatment [39,
40]. The interwoven design of this self- expanding stent enables
it to resist the risk of calcium-related crushing, to be exible
enough to be positioned at the iliofemoral junction lesions, and
to maintain any subsequent access at this level. The prospective, multicentric VMI-CFA study evaluating the Supera™
stent in the treatment of occlusive lesions of the CFA showed
100% primary patency at 6months [41].
cal outcomes of simple and complex stenting techniques,
showed no signicant difference between the two groups,
regarding the primary patency rates at 24months (simple
lesions 86.3% vs complex lesions 79%; p = 0.66) and
freedom from TLR (simple lesions 93.3% vs complex
lesions 82%; p=0.34) [45]. To our knowledge, this is the
only study from a randomized trial that compares all
endovascular treatment strategies for the CFA bifurcation.
However, as reported in the coronary literature, bifurcation lesions are one of the more complex lesion subgroups
that we are increasingly confronted with. In this eld,
many techniques have been used and described in randomized studies and meta-analysis; [46, 47] despite this
great interest for these lesions, the optimal stenting strategy remains a subject of debate. Atherectomy devices
combined with drug coating balloon could be a promising
alternative to CFA bifurcation stenting. PESTO trial is a
prospective, multicentre randomized study aiming to
compare the performance of directional atherectomy and
DCB against open surgical reconstruction in CFA lesions
(ClinicalTrials.gov Identier: NCT02517827). However,
distal embolization remains a major disadvantage with
atherectomy and hence use of embolic protection devices
is recommended [48].
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B. Nasr and Y. Gouëc
The use of self-expandable stent in the CFA decrease the
extrinsic compression and make possible a redo CFA puncture through the stent mesh. Balloon expandable stents
should be preserved for DFA and SFA ostial stenosis to
allow precise ostial positioning of the stent. Paris et al.
showed that CFA stenting did not preclude future CFA vascular access [49]. By scaffolding the vessel wall with high
radial outward force, stents improve procedural outcomes,
by avoiding the problems of elastic recoil, residual stenosis,
and dissection after balloon angioplasty. However, beyond
the acute treatment phase, scaffolding the vessel can cause
inammation and lead to intimal hyperplasia formation and
in-stent restenosis [50]. Therefore, the “combination strategy” of DCB and BMS seems to be a promising therapy.
Supera helical interwoven nitinol stent (Abott Vascular,
Santa Clara, California) in combination with a DCB and
drug-eluting self-expanding stents could offer an advantage
in term of crush resistance and potential reduction of restenosis. For the femoropopliteal lesions, the RAPID trial
compared patency rates of the LEGFLOW DCB
(Cardionovum GmbH, Bonn, Germany) in combination
with a SUPERA stent to the SUPERA stent alone [51]. The
primary patency at 1year was 68.3% in the DCB+Supera
stent group vs 62.0% in the Supera stent group (p=0.9) in
the intention-to-treat analysis and 74.7% in the
DCB + Supera stent group vs 62% in the control group
(p=0.273) in the per-protocol analysis [51].
Technological innovations in the treatment of calcied
plaque, the use of stents with specic characteristics for this
area, and the promising short- and medium-term results
allow us to consider endovascular treatment of occlusive
lesions of the femoral bifurcation as a rst-line treatment,
especially in patients at high risk of complications of scarpa.
However, we need further studies with large numbers of
patients to dene the optimal stenting technique and stent
type to be used in Azema type III lesions. We also need additional long-term data to ensure that CFA stenting does not
limit future surgical or endovascular options in cases of stent
failure. Finally, we need randomized trial comparing efcacy
of CFA stenting and “leave nothing behind” strategy for the
treatment of CFA disease.
Conclusion
A decade ago, CFA endarterectomy was considered the only
way to treat occlusive lesions of the CFA, as it was widely
considered a “no stent zone”. However, the excellent short
and medium term results of the randomized trial, the development of new techniques for vessel preparation and the
improvement of the stents used have allowed a move towards
endovascular rst-line treatment.
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Re-Entry andRecanalisation Techniques
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intheEndovascular Management
ofPeripheral Arterial Disease
GregoryMakris, MichaelParker, andTariqAli
Case Presentation
An 84-year-old female presented to the vascular surgeons
with dry gangrene of the right hallux. CT angiography demonstrated diffuse calcic stenoses of the supercial femoral
artery (SFA) with an occluded popliteal artery and singlevessel run-off to the foot via the anterior tibial (AT) artery.
Under local anaesthesia, an antegrade right common femoral artery (CFA) puncture was performed with a standard
access needle before a 4Fr catheter was advanced to the level
of the lesser trochanter to perform digital subtraction angiography (DSA). This demonstrated a long-segment occlusion
of the SFA-popliteal artery with reconstitution of ow at the
level of P3. Multifocal moderate SFA stenoses were also
seen with severe focal stenosis at the origin of the AT.Variant
anatomy was noted with the peroneal artery arising directly
from the popliteal artery above the TPT.The AT was the sole
runoff vessel (Fig.11.1).
An 0.035″ wire was advanced to P1 through the catheter
before exchanging the catheter for a 6Fr destination sheath.
5000IU heparin IA was administered at the time of insertion. Attempting to cross the SFA/popliteal occlusion with a
selection of 0.018″ and 0.014″ wires proved unsuccessful,
and therefore the decision was made to use a retrograde
puncture of the DP with a long micropuncture kit.
11
G. Makris (*)
Guys’ and St Thomas’ NHS Foundation Trust, London, UK
e-mail: g.makris@aibs.gr
M. Parker · T. Ali
Norfolk and Norwich University Hospitals, Norwich, UK
e-mail: MICHAEL.PARKER@nnuh.nhs.uk;
TARIQ.ALI@nnuh.nhs.uk
© 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_11
Fig. 11.1 LEFT: Demonstration of the SFA-popliteal occlusion.
RIGHT: Short focal proximal AT severe stenosis
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Background
Peripheral arterial disease (PAD) of the lower limb affects
approximately 230 million people worldwide and is associated with multiple negative health outcomes both locally
(ulcers, amputation) and distally (stroke, ischaemic heart
disease). PAD is a progressive disease characterised by stenosis of arteries outside the coronary, abdominal, and cerebral circulation. The lower limbs are affected more frequently
than the upper limbs with symptoms ranging from intermittent claudication to critical limb ischaemia; both of which
confer increased morbidity and mortality upon patients. The
estimated overall prevalence of PAD in Western societies is
15%, increasing to 30% in older individuals. The estimated
associated mortality rate of PAD is increasing, with 40,000
associated deaths in 2013 (an increase of 155% from 1990),
according to the Global Burden of Disease Study [5–7].
The major risk factors for PAD include smoking, hyper/
dyslipidaemia, diabetes mellitus (DM), obesity, and a family
history of PAD. Research from the National Health and
Nutrition Examination Survey demonstrated that 95% of
patients with PAD had at least one of the aforementioned
major risk factors and 70% had two or more. The American
Heart Association (AHA) and American College of
Cardiology (ACC) have identied four patient groups who
are at increased risk of PAD [8, 12]:
1. Patients aged 65 or over.
2. Patients aged 50 to 64 with major risk factors for athero-
sclerosis (smoking history, DM, hyperlipidaemia, hypertension, or a family history of PAD).
3. Patients under 50years of age with DM and one or more
additional risk factors for atherosclerosis.
4. Patients with known atherosclerotic disease in another
vascular bed (e.g. coronary artery disease, abdominal aortic aneurysm, mesenteric artery stenosis).
by the patient placing their foot in a dependent position, such
as hanging it over the edge of a bed. The diagnosis of CLI is
dependent on both clinical signs and symptoms with objective evidence of PAD such as the ankle-brachial pressure
index (ABPI) <0.9, transcutaneous oxygen tension (TcPO2)
<55 mmHg, or skin perfusion pressure < 50 mmHg. It is
worth noting that in the presence of diabetes mellitus a normal or raised ABPI should not be used to exclude PAD due
to confounding effects of calcied vessels giving a falsely
raised score [13, 14].
The Rutherford and Fontaine Classication systems are
used to quantify the severity of symptoms of PAD [12].
However, the Fontaine system is usually used for research
purposes as opposed to in routine clinical practice. The
Rutherford test aligns the severity of clinical symptoms
based on the effects of walking for 5min on a treadmill at
2miles per hour at a 12% incline with severity based solely
on the patient’s symptoms (Tables 11.1 and 11.2):
Finally, acute limb ischaemia (ALI) is dened by a
sudden- onset loss of limb perfusion within 2weeks of a vascular insult. It is a medical emergency which can result in
permanent disability, tissue loss, amputation, or death. Speed
is of the essence in managing ALI, as tissue loss can be seen
within 4–6h from the initial event. The commonest symptoms of ALI are pain, pallor, paraesthesia, absent or decreased
pulses, paralysis, and poikilothermia. Common causes of
ALI are in-situ thrombus or embolus obstructing an already
stenosed vessel, trauma, dissection, or occlusion of a stent or
bypass graft [15–18].
It is worth noting that anatomical assessment with angiography (direct or cross-sectional) or with a duplex ultrasound is only indicated in symptomatic patients who would
be considered for revascularisation. Patients who would not
be treated with revascularisation are not advised to have
imaging, as it would not change their management.
PAD of the lower limb can be broken down into four clini-
cal categories: Asymptomatic, intermittent claudication,
acute, and chronic limb ischaemia. Up to 50% of patients
with PAD are asymptomatic, often with symptoms masked
by concomitant medical comorbidities, such as decreased
mobility and peripheral neuropathy secondary to
DM. Intermittent claudication is the presence of pain or
cramping in the limb upon exertion which is often predictable and reproducible and relieved by rest. Symptoms are
most felt in the calves but, depending on the level of the stenosis, may also occur in the thighs or buttocks. Intermittent
claudication is experienced by approximately one-third of
patients with lower-limb PAD [9–11].
Critical limb ischaemia (CLI) is characterised by ischaemic pain at rest, limb ulceration, and gangrene over a
period of over 2weeks’ duration. Rest pain is usually relieved
Table 11.1 The Rutherford classication system
Grade Category Presentation
0 0
1 1 Mild claudication
1 2 Moderate claudication
1 3 Severe claudication
2 4 Ischaemic rest pain
2 5 Minor tissue loss
2 6 Major tissue loss
Table 11.2 The Fontaine classication system
Stage Clinical ndings
I Asymptomatic
IIa Mild claudication
IIb Moderate or severe claudication
III Ischaemic rest pain
IV Ulceration or gangrene
Asymptomatic
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93
Conservative Management
Management of PAD should also encompass the patient’s
increased risk of ischaemic heart disease. Patients should be
offered smoking cessation advice, antihypertensives, statins,
glycaemic control (in the presence of DM), and antiplatelet
therapy. Evidence suggests that ACE inhibitors and angiotensin- II receptor antagonists signicantly reduce cardiovascular events in patients with PAD [8, 19, 23].
The use of single-antiplatelet therapy in patients with
asymptomatic PAD and an ABPI <0.9 is controversial, with
no clear evidence to suggest that it confers improved outcomes. In saying that, it is hypothesised that the use of antiplatelet agents may benet these patients due to their
increased risk of cardiovascular events. Single antiplatelet
therapy with either aspirin or clopidogrel has been demonstrated to signicantly decrease cardiovascular events and
death secondary to vascular events in this patient population.
The Clopidogrel Versus Aspirin in Patients at Risk of
Ischaemic Events (CAPRIE) trial demonstrated that clopidogrel was superior to aspirin in reducing both cardiovascular
risk and bleeding events in patients with symptomatic
PAD. However, the VOYAGER study demonstrated that
major adverse limb and cardiovascular risks were signicantly reduced when aspirin was combined with Rivaroxaban,
although with a slightly increased risk of bleeding when
compared with Aspin alone.
Indications forIntervention
Revascularisation is indicated in patients who have been
advised on the benets of lifestyle modication, a supervised
exercise programme has not signicantly improved symptoms, and imaging has demonstrated the patient is suitable
for revascularisation [1]. In the majority of cases, a duplex
ultrasound is sufcient in patients with lower-limb PAD to
assess for suitability for revascularisation; however, should
there be any ambiguity then contrast-enhanced MRI or CT is
advised in this patient group before proceeding to intervention. It is strongly advised that patients undergo an MDT
assessment prior to proceeding to treatment for chronic PAD.
Treatment Considerations
Imaging ndings for lower-limb PAD are classied as per
the Trans-Atlantic Inter-Society Consensus on Management
of Peripheral Arterial Disease (TASC II) for both above- and
below the knee disease (Tables 11.3 and 11.4):
According to the TASC II recommendations, endovascular management is preferred for Type A and B lesions, and
surgery for Type D.Ideally Type C lesions should be surgically managed, however treatment strategies for both type B
Table 11.3 The TASC classication of radiological ndings of aboveknee PAD [2]
Classication Findings
Type A • Unilateral or bilateral common iliac artery (CIA)
stenosis, or
• Unilateral or bilateral single stenosis of the
external iliac artery (EIA) <3cm, or
• Single stenosis <10cm or single occlusion <5cm
within the common femoral (CFA) or popliteal
artery
Type B • <3cm stenosis of the infrarenal aorta, or
• Single or multiple stenosis totalling 3–10cm
involving the EIA but not extending into the CFA,
or
• Unilateral EIA occlusion not involving the
origins of the EIA or CFA
Type C • Bilateral CIA occlusions, or
• Bilateral EIA stenosis 3–10cm in length and not
involving the CFA, or
• Unilateral EIA stenosis extending into the CFA,
or
• Unilateral EIA occlusion involving the origins of
the IIA and/or CFA, or
• Heavily calcie unilateral EIA occlusion with or
without involvement of the origins of the IIA and/
or CFA, or
• Multiple CFA/popliteal stenoses or occlusions
>15cm in total length, or
• Recurrent stenoses or occlusions which require
>2 interventions
Type D • Infrarenal aortic occlusion, or
• Diffuse disease involving the aorta and both iliac
arteries requiring treatment, or
• Multiple stenoses/occlusions involving the
unilateral CIA, EIA, and/or CFA, or
• Bilateral EIA occlusions
• Chronic total CFA or supercial femoral artery
(SFA) >20cm in length and involving the popliteal
artery and proximal crural vessels
Table 11.4 The TASC classication of radiological ndings of belowknee PAD [3]
Classication Findings
Type A • Single focal stenosis <5cm in length in the target
tibial artery with occlusion or stenosis of equal or
worse severity in the other tibial arteries
Type B • Multiple stenoses each <5cm with a total
length<10cm, or single occlusion <3cm in
length in the target tibial artery with occlusion or
stenosis of equal or worse severity in the other
tibial arteries
Type C • Multiple stenoses in the target tibial artery and/or
single occlusion with a total length>10cm with
occlusion or stenosis of equal or worse severity in
the other tibial arteries
Type D • multiple stenoses in the target tibial artery
>10cm in total length with dense calcication and
non-visible collaterals with occlusions or dense
calcication in the other tibial arteries
and C lesions should be designed with the patient’s preferences, comorbidities, and local practice and experience in
consideration.
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Pre-Procedural Assessment
Prior to each procedure, a full medical assessment is required
to ensure that the patient is t for treatment. A full blood
count, coagulation screen, and renal function are advised to
ensure there are no contraindications to treatment. It is advisable for the patient to have a Hb >80, Platelets >80, and INR
of <1.5, however in emergency situations these can be overridden by the supervising clinician should clinical need preclude waiting for intervention. The main risks from treating
a patient with thrombocytopaenia or a raised INR are from
bleeding, either intra-procedurally or when trying to achieve
haemostasis at the end. The importance of renal function
comes when considering the potentially nephrotoxic effects
of iodinated contrast medium, especially in long cases in
which multiple angiograms may be required.
It is also inadvisable to perform an arterial puncture on a
patient with signicant hypertension (systolic blood pressure>200) due to difculties in achieving haemostasis postprocedurally, and in elective patients, it is also prudent to not
proceed should the patient be systemically unwell due to the
risk for potential complications intra- or post-procedurally.
Regarding anticoagulation such as warfarin or DOACS,
the drugs should be stopped pre-procedurally to decrease the
chance of haemorrhagic complications. Warfarin is commonly stopped 7 days’ pre-procedurally whereas DOACS
such as Rivaroxaban or Apixaban should be stopped for
2days’ pre-procedurally. These patients can be given bridging low molecular weight heparin (LMWH) should bridging
be required. There is no need to stop antiplatelet agents such
as aspirin or clopidogrel.
Endovascular Strategy andTechnique
The BASIL trial compared outcomes in patients with lower
limb ischaemia treated with either a surgery-rst or
angioplasty- rst strategy with a primary endpoint of
amputation- free survival. It suggested that outcomes were
similar for both treatments (in suitable patients) with the
consideration that percutaneous angioplasty was a more
cost-effective option.
The success of percutaneous transluminal angioplasty
(PTA) is multifactorial, including the type and severity of
PAD, lesion length, vessel quality, associated diseases (DM,
IHD), and persistent risk factors such as smoking and hypertension [4]. The probability of technical success for PTA is
greater in the iliac arteries and decreases in more distal vessels. Evidence suggests that the technical success of PTA and
primary stenting in aortoiliac occlusive disease is 96% with
primary and secondary patency rates of 63% and 86%
respectively, which is comparable with surgical bypass.
Furthermore, this patient subgroup had a 26% increase in
walking distance in the 2years’ post-intervention with associated increased physical function and decreased limb pain.
In the femoral arteries, stenting is reserved for patients who
have a technical failure of PTA or who have recurrent stenosis in fewer than 3months’ post-procedure.
It is often advisable that patients suffering from intermittent claudication are treated with less aggressive management strategies than those with CLI.Lesions are dened as
signicant should the stenosis comprise >50% of the vessel
lumen. Lesions which cause less than 50% luminal narrowing are usually not deemed clinically signicant and therefore are unlikely to benet from PTA or surgical
intervention.
Basic Endovascular Toolkit
The vast majority of procedures are performed under local
anaesthesia. However, general anaesthesia is employed if the
procedure is done in combination with surgery or if the
patient is non-compliant.
For a standard lower limb PTA, the commonly used kit
includes:
• Vascular access needle.
• Standard access wire (usually “J” tip).
• Selective catheter(s).
• Vascular access sheath(s) – range in size but typically
4Fr-7Fr sheaths are used for endovascular procedures,
depending on adjuncts required during the procedure
such as stents, re-entry catheters, and atherectomy
devices.
• Angioplasty balloons sized to the lesion on pre- procedural
imaging.
• Ination device.
• Bare-metal stents sized to 10% larger than the vessel
diameter of varying lengths. Should iliac work be under-
taken, then it is sensible to have access to appropriately
sized covered stents, especially in heavily calcied
vessels.
• Closure devices such as Prostyle™ or Angioseal™; how-
ever, with the latter precludes further intervention at the
same access vessel in the next 90days.
General Access
Access is primarily via the common femoral artery at the
level of the mid-femoral head within the centre of the anterior aspect of the vessel, or “12 o’clock”. In the presence of
complex aorto-iliac occlusions then upper limb access can be
considered, for example via the brachial artery. The puncture
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