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A. Diamantopoulos and I. Theodoulou
Symptoms can present as paraesthesia in the affected limb,
ischaemic symptoms such as IC due to arterial steal, peripheral oedema and venous insufciency. Majority of acquired
AVF tend to resolve spontaneously within 2months, therefore conservative management with observation is the default
management option for majority of patients. Follow-up
ultrasonography is recommended at 30days to conrm closure of the connecting tract. Clinical indications for active
treatment include signicant enlargement conrmed on surveillance scanning and worsening symptomatology or persistence beyond 1 year.
Management Options
1. Ultrasound-guided compression: this technique resem-
bles the one employed for pseudoaneurysm management
with probe placement instead focusing on the actual AVF
(instead of across the pseudoaneurysm neck). However,
this is rarely successful.
2. Endovascular repair: this is considered an acceptable
technique as it is minimal invasive and an open repair is
avoided. It is more appropriate for patients with acquired
AVF who would not tolerate surgical repair either due to
small margins for bleeding (low baseline Hb) or a hostile
groin (if in femoral region) due to signicant brosis
from previous surgical exploration. With increasing experience worldwide, endovascular options have become
more widely used even for patients who are good surgical
candidates. Endovascular approaches include placement
of covered stents or embolisation depending on the location of the AVF.Alternatively, provided there is an adequately visualised and sufciently long connecting
channel, the AVF might be amenable to embolisation
techniques such as coiling. Surgical repair remains the
gold standard for t enough patients.
Angioplasty Site Complications
has an incidence of 6.1% and is more common in the femoropopliteal region and associated more with covered nitinol
stents than BMS [12]. Symptoms are in keeping with acute
limb ischaemia and manifest more acutely.
Management Options
Prompt recognition and management of peripheral acute
thrombosis is critical to avoid foot amputations. Treatment
commonly consists of catheter-directed thrombolysis with or
without mechanical thrombectomy. The latter is the treatment mode of choice if contraindications to thrombolysis
apply. Refractory lesions might need to be referred for surgical bypass with success rates reported up to 95% for lesions
in the supercial femoral region [13].
Dissection
Inadvertent arterial injury in the form of dissection at diseased segments is a common complication, arising, in some
reported cohorts up to 84% [14]. Dissection is dened as a
tear between layers of an artery, typically the intima and the
media. This can arise in two ways: (1) inadvertent subintimal
puncture and introduction of a wire while crossing occlusions, or (2) during balloon expansion which promotes
plaque ssuring due to radial stresses exerted by the inated
balloon [14]. Intravascular Ultrasound (IVUS) has been
investigated and utilised more extensively than angiography,
duplex ultrasonography or optical coherence tomography for
identication and characterisation of arterial dissections.
Kobayashi Grading [15] and iDissection classication systems (Tables 21.1 and 21.2) [16] help describe lesions with
the limitation that they both omit the length of dissections
and the presence of haematomas. The immediate clinical
implications of dissections include ow limitation and have
also been associated with decreased long-run patency even
with low-grade lesions. Consensus is for intraprocedural
treatment of dissections upon identication, regardless of
severity.
Thrombosis
Stent occlusion and acute thrombosis are closely related but
fundamentally different complications in PVI, with the former constituting a common subacute complication due to
intimal hyperplasia at the site of angioplasty, and the latter
describing an immediately apparent thrombosis of the angioplasty site shortly after deployment of stents. Acute thrombosis is a limb-threatening condition and arises
intraprocedural most of the times and contrary to stent reocclusion it lacks collateralisation, therefore rendering it an
emergency. Recent analyses suggest that acute thrombosis
Table 21.1 The Kobayashi grading proposal [15]
Category Width of dissection
Group A None
Group B <1/3 lumen
Group C >1/3 lumen
Table 21.2 The iDissection classication scheme [16]
Dissection Circumference <180° Circumference >180°
Intima A1 A2
Media B1 B2
Adventitia C1 C2
21 Complications andTheir Management inPeripheral Interventions
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Fig. 21.2 Schematic coronal
representation of a normal
artery, an aneurysmal and a
pseudo-aneurysmal artery
213
Management Options
Based on coronary experience, dissections can generally be
treated with prolonged, low-pressure inations across dissected segments with oversized balloons [17]; this aims to
reappose obliterated arterial layers. This is a more appealing
technique for the infrapopliteal territory where data is generally more limited. Stent implantation remains the rst line
approach in the femoral and aortoiliac regions, with either
entire lesion stenting or angioplasty followed by spot stenting to tackle areas with signicant ow limitations.
Management options will also likely vary depending on the
extent of dissection and whether this tracks distally with
ow-limiting implications. The choice between nitinol bare
metal stents (BMS), drug-coated balloons and drug-eluting
stents (DES) is an ongoing topic of research (Fig.21.2).
Arterial Rupture
Vessel rupture arises via two mechanisms, the commoner of
which is due to inadvertent passage of wire into the subadventitial space followed by post-dilatation of implanted
stent. Less commonly, it might arise with overdilation or
oversized balloons. In PVI, iliac artery rupture manifests
immediately with severe pain secondary to retroperitoneal
haematoma and sudden haemodynamic compromise.
Management should be instigated immediately.
Management Options
Principles of management consist of rupture identication, bleeding control with proximal balloon tamponade
and patient resuscitation and stent-graft deployment in the
affected segment. For iliac artery ruptures identied with
angiographic contrast extravasation, proximal tamponade
in the aortoiliac section with an appropriately sized balloon should be established to control bleeding and prepare
for the deployment of a stent graft across the ruptured segment. If upsizing of sheath is necessary to enable graft
employment, more proximal tamponade should be pursued in the common iliac or aortic segments. Like dissections, ruptures in the femoropopliteal region are often
resolved with prolonged balloon dilatation. Persistent
femoropopliteal ruptures are amenable to stent-grafting
and reversal of anticoagulation might be considered in
refractory cases. Surgical escalation might be necessary if
the above fail.
Distal Emboli
This can occur with any type of PVI and can lead to catastrophic consequences for the patient without timely recognition and treatment. This is more pertinent for distal
embolisations in the lower extremity in which microemboli
can lead to trash foot which in itself is associated to high
mortality and morbidity. Blue toe syndrome represents
distal- most embolisations in end arteries affecting digital circulation but with patent proximal large vessels. As the name
suggests, skin discoloration and pain are the main symptoms
and clinical course varies from spontaneous resolution to
gangrene requiring toe amputation. Incidence for macroembolic distal embolisations are estimated to be up to 5% [18];
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A. Diamantopoulos and I. Theodoulou
however, incidence for microembolic embolisation has not
been formally reported, possibly due to less immediate clinical implications. Recognition of on-table distal embolisations typically happens on completion angiography and
presents either with new lling defects when compared to
initial crossing catheter angiography or lost patency in run
off vessels.
Management Options
Operator should rst conrm adequate anticoagulation using
activated clotting time (ACT) which is consensually agreed
as optimal when between 200 and 250s. Depending on the
anatomical site and size of the dislodged thrombus there are
two options: surgical thrombectomy or intra-arterial catheterbased approaches. Different subtypes of pharmacomechanical approaches are considered after screening for absolute
contraindications for thrombolysis such as recent established
cerebrovascular accidents (CVA), known bleeding diatheses,
recent gastrointestinal or intracranial bleeds [19]. In the
absence of contraindications, as an adjunct to clot aspiration
systems such as Angiojet, rheolytic technology can be
employed which infuses small amounts (2–4mg) of tissue
plasminogen activator (tPA). If thrombolysis contraindications apply, transcatheter mechanical embolectomy alone is
employed. Open embolectomy options are sought if embolic
material is insufciently retrieved using catheter-based
approaches.
Systemic Complications
Allergic Reactions
This is often associated not only to iodine contrast-related
reactions, including anaphylaxis, but also implantable endovascular devices, including BMS (allergy to metal ions) and
DES (allergy to coating polymers).
Management
Management algorithms for allergic reactions is no different
to all other anaphylactic-like reactions and should include
easy and prompt access and administration of adrenaline,
uids antihistamine and steroid treatments.
Renal Failure
Contrast-induced nephrotoxicity (CIN) or contrastassociated acute kidney injury (AKI) (CA-AKI) is an AKI
presumed to have been caused by contrast material employed
in an endovascular procedure. CA-AKI is the most favourable term amongst the two, as CIN implies a causal link
between contrast and AKI which is often hard to prove clinically. Diagnosis of CA-AKI is made in the presence of signicant creatinine rise 24–48h post-procedurally and after
all other causes of AKI have been excluded.
Management
Management principles are identical to other causes of AKI,
with appropriate uid balance assessment and electrolyte
monitoring with replacements where appropriate. Dose
adjustment of regular and new medications is also important
considering the reduced creatinine clearance.
Case Presentation
Continued from page 209
Given the size of the pseudoaneurysm which exceeded the
3cm cut-off normally used to guide the management of pseudoaneurysm, a decision was made to treat this with ultrasoundguided thrombin injection rather than opting for conservative
management. During the ultrasound assessment, a note was
made of the sac size and the width of the neck, which were
4cm and 0.5cm, respectively. Using a sterile technique, local
anaesthesia was performed in the right-groin area under ultrasound guidance, including around the site of pseudoaneurysm.
Using an off-the-shelf ‘thrombin kit’, which comes with thrombin concentration of 100units per 1mL, injection of thrombin
was performed under ultrasound guidance in 10-unit increments until ow was seen to arrest within the pseudoaneurysm
sac, as assessed by duplex imaging. To conrm satisfactory
ow resolution, scanning was performed 10min later which
conrmed. Patient was kept in the department for 6h for monitoring and later discharged with advice, including bed rest and
activity modications such as avoiding heavy lifting and regular analgesia. Repeat ultrasound imaging was performed 2days
later to conrm successful treatment and resolution of the pseudoaneurysm. Overall summary of complications and their
management described in (Tables 21.3 and 21.4).
21 Complications andTheir Management inPeripheral Interventions
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Table 21.3 Overview of puncture site and angioplasty site complications
Clinical picture Risk factors Classication Treatment
Puncture site complications
Haematoma • Local pain
• Bruising
+/− expanding
• Distal neuropathy
Pseudoaneurysm • New mass
+/− pulsatile
• Local pain, swelling
• Bruising
• Distal neuropathy
AV F • Ipsilateral
paraesthesia
• Unilateral oedema
• Intermittent
claudication
Angioplasty site complications
Thrombosis • Acute limb
ischaemia
Dissection • Asymptomatic • Subintimal techniques
Vessel rupture • Severe pain
• Hypotension
Distal emboli • Skin discoloration
• Pain
• Anticoagulation
• Difcult access
• Obesity
• Anticoagulation
• Difcult access
• High BMI
• Therapeutic catheterisation
• Puncture inferior to CFA
• Female sex
• High BMI
• Anticoagulation or
antibrinolytic therapy
• Femoro-popliteal region
• Covered nitinol stents
• Oversized balloons
• Balloon overdilatation
• Subintimal techniques
• Steroid use
• Fibromuscular dysplasia
• Vasculitis
• Atherectomy
• Long procedure
• Inadequate anticoagulation
– Size
– Location
– Complicated
– No. of lobes
– Neck width
– Neck length
– Sac diameter
– 1. US-guided compression
– 1. Catheter-directed
– Kobayashi
– iDissection
– Location 1. Stent-graft deployment
– Microembolic
– Macroembolic
1. Manual compression
2. Covered stenting
3. Surgical evacuation
1. US-guided compression
2. US-guided thrombin
2. Surgical repair
3. Endovascular coiling
4. Covered stenting
thrombolysis
2. Mechanical thrombectomy
3. Surgical bypass
1. Prolonged inations
2. Stenting
2. Surgical open repair
1. Endovascular
Pharmacomechanical
2. Open thrombectomy
215
Table 21.4 Basic toolkit for the management of complications
Basic toolkit for the management of complications
• Compression dressings
• Endovascular covered stents
• Nitinol bare metal stents (BMS), drug-coated balloons,
drug-eluting stents (DES)
• Thrombin kits
• Clot aspiration systems such as Angiojet
• Tissue plasminogen activator
• Anaphylaxis kits
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SD, Paraskevopoulos I, etal. Peripheral stent thrombosis leading
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Follow-Up andSurveillance After
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Peripheral Interventions
PanagiotisVolteas andNicosLabropoulos
22
Case Presentation A 69-year-old woman presented to the
clinic with a 2-month history of worsening right lower
extremity rest pain (Rutherford class 4). The patient was a
current smoker with past medical history of hypertension,
and hyperlipidemia. On physical examination, she had no
ulcerations, and normal lower extremity sensory and motor
function. On the right side she had palpable femoral pulse,
and dopplerable dorsalis pedis (DP) and posterior tibial
(PT) signals. On the left lower extremity, the patient had
palpable femoral and DP/PT pulses. The right ankle/brachial index (ABI) was 0.4 and the left ABI was 0.8 while a
Duplex US showed severe supercial femoral artery and
popliteal artery (P1 and P2 segments) stenosis. Based on the
above the decision was made to proceed with right leg angiography, during which the supercial femoral artery and the
P1/P2 segments of the popliteal artery underwent balloon
angioplasty followed by stents placement. Completion angiography showed resolution of the severe stenosis and two
vessel runoff to the foot. The patient was placed on aspirin,
plavix and statin with a plan to follow up at 1month with
ABIs and arterial DUS.
Continued at page 221
Advances in endovascular therapies have established
percutaneous interventions as a preferred alternative to open
surgical revascularization not only in cases of intermittent
claudication but also in patients with chronic limbthreatening ischemia (CLTI) [1, 2]. The major drawback
after endovascular interventions is restenosis which can
progress to arterial occlusion with direct consequences to
limb salvage [3]. Restenosis is mainly related to a combina-
P. Volteas
Vascular and Endovascular Surgery, Stony Brook Medicine,
Stony Brook, NY, USA
N. Labropoulos (*)
Surgery and Radiology, Vascular Laboratory, Stony Brook
Medicine, Stony Brook, NY, USA
tion of arterial wall inammatory remodeling and neo-intimal hyperplasia most commonly at the balloon dilation site,
atherectomy site, or at the proximal or distal end of a stent.
It can also be related to initial suboptimal procedural results
due to residual >50% stenosis, residual dissection, distal
embolization, stent fracture, inadequate inow or outow
treatment or progression of the peripheral atherosclerotic
disease [3, 4].
Although postoperative surveillance imaging is routinely performed for patients after carotid artery interventions, less than half of patients receive any follow-up after
lower extremity interventions, even in Vascular Quality
Initiative (VQI) participating hospitals where follow-up
care is prioritized [5, 6]. The importance of frequent follow
up is highlighted by the fact that loss to follow-up 1year
after lower extremity peripheral vascular intervention is
associated with higher prevalence of critical limb ischemia,
risk for urgent re-intervention and worse survival [7]. Thus,
every effort should be made to prolong interventions durability and to detect clinically signicant problems at an
early stage when they can be managed most safely and
effectively.
Despite the low quality of existing evidence, the Society
for Vascular Surgery has published guidelines on follow-up
after endovascular surgery peripheral arterial procedures
(Table22.1).
A typical postoperative regimen consists of performing
clinical examination, measuring the ABI/TBI, and obtaining
duplex studies at 1, 6, and 12months and then yearly thereafter, as long as there are no new signs or symptoms. The
more vigorous follow up during the rst year is supported by
the fact that most restenosis occurs in the rst 6–12months
[2, 8]. After 12months patients should continue to be followed as the progression of native disease and late restenosis
can still affect angioplasty and stent patency [9].
The surveillance should not only focus on the revascularization site but must include the completely revascularized
limb as well as the contralateral limb, along with a general
clinical cardiovascular surveillance.
© 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_22
217
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Table 22.1 The Society for Vascular Surgery practice guidelines on follow-up after endovascular surgery peripheral arterial procedures [3]
Level
Aortoiliac We recommend clinical examination, ABI, and DUS within the rst month after aortoiliac
segment EVT to provide a post-treatment baseline and to evaluate for residual stenosis
Clinical examination and ABI, with or without the addition of DUS, should be performed at
6 and 12months and then annually as long as there are no new signs or symptoms
Femoropopliteal We suggest clinical examination, ABI, and DUS within the rst month after femoropopliteal
artery EVT to provide a post-treatment baseline and to evaluate for residual stenosis
Continued surveillance at 3months and then every 6months is indicated for the following:
A. Patients with interventions using stents because of the potential increased difculty of
treating an occlusive vs stenotic in-stent lesion
B. Patients undergoing angioplasty or atherectomy for critical limb ischemia because of
increased risk of recurrent critical limb ischemia should the intervention fail
Tibial We suggest clinical examination, ABI, and DUS within the rst month after tibial artery
EVT to provide a posttreatment baseline and to evaluate for residual stenosis
Continued surveillance at 3months and then every 6months should be considered. Those
patients with a deteriorating clinical vascular examination, return of rest pain, non-healing
wounds, or new tissue loss should undergo repeated DUS
P. Volteas and N. Labropoulos
Strength of recommendation
quality of evidence
1 (strong)
C (low)
2 (weak)
C (low)
2 (weak)
C (low)
Clinical Examination
The patient’s functional activity, the presence of recurrent claudication symptoms or signs, and the healing status of wounds
in case of CLTI should be evaluated. This can be done by comparing the patient’s limb ischemia stage according to the
Rutherford scale both pre- and post-intervention. Patients can
be considered clinically improved if they move up at least by
one clinical category in the Rutherford classication, but those
with actual tissue loss need to move up at least two categories
to reach a level of claudication that can be considered improved.
Cardiovascular surveillance including modication of
atherosclerotic risk factors, counseling on smoking cessation, reduction to an ideal body weight with diet and exercise,
preventive foot care and medical therapy are important
aspects of postoperative management [2]. Optimal medical
management usually includes the use of single or dual antiplatelet therapy, lipid-lowering agents, antihypertensive
medications, and glycemic control agents [10]. Despite an
absence of strong clinical evidence, dual antiplatelet therapy
(DAPT) is frequently employed for 1–6months followed by
subsequent indenite therapy with either aspirin or clopidogrel [2, 11]. Aspirin has been the mainstay of treatment
because it is efcacious and cost-effective, but clopidogrel
can also be effective as a single agent [11].
Assessment ofLimb Perfusion by Physiologic
Testing (Pulse Exam, ABI/TBI/Toe Pressures)
Each follow-up visit should include careful examination
of the feet to confirm the presence of pedal pulses, capillary refill, any signs of ischemia (dependent rubor, ulcer-
ation, non-healing wounds, gangrene) or any change
from the baseline examination [2]. Wound prevention
education and wound care until wounds are healed are
equally essential to long-term clinical success after
peripheral arterial procedures, especially in those with
CTLI [2, 4].
Post-intervention, an increase of more than 0.10in ABI
is indicative of improved ow. On the contrary a drop in
ABI of more than 0.15 could indicate restenosis at the site of
intervention or emergence of de novo disease outside the
treated segment, such as in the inow or outow. In cases of
recurrent claudication, the functional severity is better
assessed with post-exercise treadmill test ABI.The magnitude of the decline when reintervention should be considered has not been well studied, but a decline of more than
0.15 compared to baseline ABI immediately after the procedure should trigger an evaluation with duplex ultrasound
(DUS) [2].
In patients treated for CLTI and in those with diabetes
mellitus in whom the ABI cannot be accurately measured,
the systolic toe pressure should be measured as it is less
commonly affected by vessel calcication and incompressibility. In general, a toe pressure greater than
30mmHg is required to relieve rest pain, while a toe pressure greater than 40mmHg can reliably predict successful
wound healing. The combination of the above information,
expressed as the WIfI score (Wound, Ischemia, and foot
Infection) is very important especially in patients with
CLTI. The WIfI score should be recalculated after any
intervention, as restaging has proved to be an important
tool for predicting limb loss and assessing the adequacy of
the intervention [12].
22 Follow-Up andSurveillance After Peripheral Interventions
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219
Duplex US Evaluation forAnatomic or Flow
Abnormalities
Surveillance by clinical follow-up alone may be insufcient
to detect restenosis as patients may remain asymptomatic
until the target artery has occluded (Fig.22.1) [11]. ABI adds
signicant information to clinical examination, but it correlates poorly with angiographic stenosis, and a signicant
decrease in ABI (>0.15) may not be present until a greater
than 60% stenosis exists [4]. Judicious use of DUS seems to
be superior to ABI and is a pivotal imaging technique for
identifying revascularization failures [13].
A baseline DUS within the rst month after endovascular
treatment (EVT) is recommended for all patients undergoing
lower extremity interventions to establish a post-treatment
baseline and to identify those with residual stenoses missed on
completion angiography [3]. Optimally, detailed description of
the procedure and previous DUS examinations should be available for the sonographer. The inow, area of procedure, and
outow should be assessed. Anatomic information using direct
visualization of the vessel as well as physiologic information
based on spectral waveforms, and velocity measurements
should be used to characterize any stenosis. These modalities
will help also to determine other pathologies such as stent malposition, thrombosis, wall apposition, evidence of kinking, dissection, stent fracture, and progression of disease (Table22.2).
Table 22.2 Duplex ultrasound characteristics
Indications for
DUS follow-up
Inappropriate
follow-up
Assess
– Inow
– Area of
procedure
– Outow
DUS modalities
– B-mode
– Color
Doppler
– Spectral
waveform
– Velocity
criteria
• During procedure
• 1month
• 6months
• 12months
• Then annually or as needed for clinically
worsening symptoms
• Patients without physical exam
• Unrelated symptoms
• Random follow-up
• Frequent follow-up
DUS pathologic ndings
• Stenosis
• Thrombosis
• Kink
• Dissection
• Aneurysm
• Pseudoaneurysm
• Fistula
PSV PSV
Normal
(<50%)
Moderate
(50–69%)
Severe
(70%)
Occluded No ow – No ow
<200cm/s <2 Triphasic
200–
300cm/s
300cm/s 3 Damped,
• Hematoma
• Seroma
• Infection
• Wall apposition
• Stent fracture
• Progression of
disease
• Systemic disease
Distal artery
ratio
spectral
waveform
2–3 Monophasic
monophasic
Tardus-parvus
waveform
Fig. 22.1 Duplex US images of a 69-year-old female with right lower
extremity rest pain (Rutherford class 4) s/p right supercial femoral
artery (SFA) and popliteal artery (PA) stents placement who was lost to
follow up for 1year. Patient presented with recurrent rest pain and was
found to have SFA and PA stent thrombosis on Duplex US.Dorsalis
pedis (DP) artery with parvus (prolonged systolic acceleration) and tardus waveform (small systolic amplitude and rounding of systolic peak),
due to reduced magnitude of blood ow to the DP from collateral
circulation
220
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P. Volteas and N. Labropoulos
The nding of triphasic waveform with normal PSV and
PSV ratio indicates that no signicant pressure gradient is
present. Monophasic waveform at the stenosis site, parvus
and tardus waveform distal to stenosis, spectral broadening,
and an increase in PSV and PSV ratio are ndings indicative
of critical ow-limiting stenosis. In cases of iliac stent, as
visualization can be challenging because of the presence of
bowel gas and body habitus, poor monophasic duplex waveform at the CFA is an accurate marker of more proximal aortoiliac obstructive disease [14].
Restenosis has generally been dened as >50% narrowing of the luminal diameter or >75% reduction of the crosssectional area of the artery [3]. The combination of PSV and
PSV ratio measurements (Table 22.2) offers high positive
predictive value for identifying moderate and severe restenosis that correlates with angiographic ndings [11].
Although PSV >300cm/s is indicative alone of severe instent stenosis, the PSV ratio >3.0 as well as PSVs <45cm/s
throughout the stent, are more reliable markers for predicting stent thrombosis [15–17]. Any restenosis greater than
70% (DUS: PSV >300cm/s and PSV ratio >3) should be
considered as an indication for reintervention [2, 9].
Although the PSV ratio is the most tested criterion for
detecting stenosis in peripheral arteries, in cases in which
the stenosis is very tight, this ratio is paradoxical and should
not be considered. The decreased velocities and the great
luminal reduction seen on color mode would be more appropriate to characterize the re- stenosis severity in these
patients.
In rare circumstances, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) can
be utilized for conrmation and investigation of duplex ultrasound ndings in order to obtain more detailed anatomic
information before re-intervention [11].
Patency rate depends on many factors including patient
demographics (gender, diabetes mellitus), the indication for
intervention (intermittent claudication versus CLTI), TASC
II classication, especially class C and D (location of lesion,
occlusion vs stenosis, length, calcication, number of
lesions, multilevel disease), runoff grade, and procedurerelated factors (use of various balloon angioplasty devices,
atherectomy devices, and stent grafting, vessel dissection,
nal interventional outcome) [2, 4, 5, 8, 18]. Figure 22.2
demonstrates a case where poor wall apposition of the stent
led to early restenosis. Care should be taken to optimize the
interventional outcome and minimize potential
complications.
Different levels of lower extremity peripheral arterial
disease also have different patency rates after endovascular interventions. The primary patency of aortoiliac stenting is the highest: 93% at 1year, 83% at 3years, and 78%
at 5years. Furthermore, treatment of iliac artery restenosis is associated with very high success rates, even in
cases of occlusions [3]. Primary stent patency rate
decreases substantially in case of a stent in both common
and external iliac arteries, long stents more than 6cm and
poor runoff [19]. The femoropopliteal level is the most
treated arterial segment and even complex lesions are
Fig. 22.2 Duplex US images of a 65-year-old male with left lower
extremity intermittent claudication (Rutherford class 3) s/p left supercial femoral artery (SFA) stent placement. Surveillance DUS at 1month
showed severe left SFA in stent restenosis (PSV ratio: 342/89=3.8) due
to poor intraoperative judgment of arterial diameter leading to poor
stent-wall apposition
22 Follow-Up andSurveillance After Peripheral Interventions
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221
amenable to percutaneous interventions due to the use of
a variety of devices and techniques (angioplasty, baremetal stents, drug-eluting stents, stent grafts, atherectomy
devices). Many factors can predict the primary patency
after stent placement, among them the modied Society
for Vascular Surgery runoff scoring system [20]. Tibial
artery interventions are usually done for critical limb
ischemia and are associated with low patency and high
restenosis rates [3, 21]. Again, pedal runoff score can be
valuable in identifying those patients who will not achieve
ulcer healing, amputation-free survival, and freedom from
major adverse limb events [22].
Many patients with intermittent claudication do not need
intervention other than best medical therapy and exercise as
shown in Fig.22.3. Both best medical therapy and exercise
are very important to protect the patient from cardiovascular
events, even if an intervention is planned. As patency
depends on so many factors, predicting which interventions
are more prone to failure has proved challenging. Moreover,
recurrent symptoms may be masked in patients with multilevel interventions and those with extensive collateral circulation and may not be apparent until the angioplasty segment
or the stent is occluded [2]. It should be emphasized that the
decision to treat any re-stenosis incorporates the combination of clinical symptoms, ABI changes and duplex ultrasonographic ndings and should be weighed against the
patient’s functional status, comorbidities, and the potential
morbidity associated with any reintervention (Fig.22.4). In
clinically relevant restenosis or occlusion, reintervention
should be individualized based on risk factors predictive of
procedural morbidity with endovascular approach being
considered as the rst-line treatment over open surgical
intervention [4].
Case Presentation
Continued from page 217
The patient was lost to follow-up for 1year, at which
point she presented with recurrent worsened rest pain and
new ndings of toe tissue loss. She continued to smoke
and was not compliant with her antiplatelet medications.
She had palpable femoral pulses, and Dopplerable right
leg DP/PT signals. Duplex US revealed thrombosis of the
previously placed femoral and popliteal artery stents.
Dorsalis pedis (DP) artery had parvus (prolonged systolic
acceleration) and tardus waveform (small systolic amplitude and rounding of systolic peak), due to reduced magnitude of blood ow to the DP from collateral circulation
(Fig.22.1). The patient underwent a femoral to popliteal
artery (P3 segment) bypass for restoration of arterial blood
ow. She quit smoking, started a supervised exercise pro-
gram, remained compliant with her medications, and with
her follow up appointments (Right ABI: 0.8, DUS: patent
bypass with two vessel runoff) and was able to heal the toe
ulcerations.
Fig. 22.3 Duplex US images of a 49-year-old female with bilateral
300-m intermittent claudication and bilateral SFA occlusion with good
collaterals and distal recanalization with 3 vessels runoff. She was
placed on best medical therapy and exercise regimen. Follow up at 1, 2
and 4 years showed no changes in the ABI and ultrasound imaging.
Patient remained stable and required no other intervention
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