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31 Infrainguinal Disease
Fig. 31.2 Duplex ultrasound.
Duplex ultrasound images of
the same 53-year-old male in
Fig.31.1 with left leg
claudication prior to stent
placement. (a) The patent,
proximal left SFA is shown
with biphasic waveform and
normal ow velocity
(111cm/s). (b) Focal
narrowing seen in the mid
SFA stenosis. (c) Mid SFA
stenosis demonstrating
increased ow velocity
(340cm/s)
345
346
D. Suttle and L. R. Wilkins
Fig. 31.3 Computed tomography angiography. CTA of a 59-year-old
male with bilateral lower extremity claudication and right distal SFA
occlusion. (a) Patent right SFA (arrow) proximal to stenosis. (b)
advantages of angiography are that it still provides the highest resolution of small branches and provides an opportunity
for single-stage evaluation combined with immediate treatment if needed.
Conventional Therapy
Medical treatment of PAD is aimed toward risk factor modication and pharmacologic therapy. Patients with atherosclerosis should undergo smoking cessation, exercise programs,
and diet modication. Pharmacologic interventions include
antiplatelet therapy (aspirin, clopidogrel), lipid-lowering
agents (statins, brates, niacin), antihypertensives (ACE
Complete occlusion of right distal SFA (arrow). (c) Reconstituted proximal popliteal artery distal to occlusion. (d) Coronal 3D reformatted
image of right distal SFA occlusion (arrows)
inhibitors [18], thiazides, calcium channel blockers, etc.),
and cilostazol [2].
Surgical treatment of lower extremity PAD includes
atherectomy, arterial bypass, and amputation. Bypass allows
many different anatomic congurations and uses either
autologous vein grafts (typically saphenous vein), CryoVein,
or synthetic grafts. There are longer patency rates overall
with autologous saphenous vein grafts versus synthetic.
However, this approach has an overall higher morbidity rate
and longer recovery time than an endovascular approach
[13]. Less than 2% of patients with lower extremity PAD
require amputation which is the last resort in treatment and
typically necessitated by overwhelming infection, poor healing potential, or factors related to quality of life [1].
31 Infrainguinal Disease
347
Interventional Therapy
While the eld of IR began by using balloon angioplasty to
treat a lower extremity arterial stenosis, much debate remains
around the techniques and indications of an endovascular
approach. The TASC II (Trans-Atlantic Inter-Society
Consensus) guidelines (Table 31.4) provide a starting point
for deciding between surgical and endovascular treatment.
The approach for treatment of femoral and below-the-knee
vascular disease is very different, and therefore separate
guidelines have been established for supra- and infrainguinal
disease. Although TASC II is outdated, it provides a general
guideline to endovascular rst versus surgery rst for femoral disease. At this time, there is no substantial data to compare surgical versus endovascular repair for infrapopliteal
lesions [1]. Nonetheless, IR techniques for the treatment of
lower extremity PAD remain on the forefront of advances in
treating infrainguinal disease.
Percutaneous Transluminal Angioplasty
The classic, initial treatment for most atherosclerotic lesions is
percutaneous transluminal angioplasty (PTA) [19]. Angioplasty
should be reserved for hemodynamically signicant lesions,
which are typically classied as those with greater than 50%
luminal stenosis [20]. Balloon dilatation is done via an ipsilateral or contralateral common femoral arterial access. An antegrade, ipsilateral approach, allows more technical ease for PTA
without tension created by bending the guidewire and catheter
over the femoral bifurcation as is required for the contralateral
femoral (retrograde) approach. However, due to increasing
obesity rates, this technique can present increased difculty
with hemostasis after the procedure, and a contralateral “up
and over” approach is more common [21].
Fig. 31.4 Magnetic resonance angiography. Coronal image from a
bilateral lower extremity MRA of an 82-year-old male with a patent left
femoral-popliteal bypass graft (thin arrows) and right non-healing foot
ulcer. There is a right SFA occlusion (thick arrows) with distal reconstitution at the adductor canal
Table 31.4 TASCII classication of infrainguinal atherosclerotic lesions [3]
Class Description Lesion
A Yields excellent results from, and should be
treated by, endovascular means
B Sufciently good results with endovascular
methods that this approach is still preferred
rst, unless an open revascularization is
required for other associated lesions in the
same anatomic area
C Produce superior enough long-term results
with open revascularization that endovascular
methods should be used only in patients with
high risk for open repair
D Do not yield good enough results with
endovascular methods to justify them as
primary treatment
Single stenosis <10cm in length
Single occlusion <5cm in length
Multiple lesions (stenoses or occlusions), each <5cm
Single stenosis or occlusion <15cm not involving the infrageniculate popliteal artery
Single or multiple lesions in the absence of continuous tibial vessels to improve inow
for a distal bypass
Heavily calcied occlusion <5cm in length
Single popliteal stenosis
Multiple stenoses or occlusions totaling >15cm with or without heavy calcications
Recurrent stenoses or occlusions that need treatment after two endovascular
interventions
Chronic total occlusions of CFA or SFA (>20cm, involving the popliteal artery)
Chronic total occlusions of popliteal artery and proximal trifurcation vessels
Key Point
Percutaneous transluminal angioplasty (PTA) is
reserved for luminal stenosis >50%.
348
The How To: Angioplasty and Stenting
1. Ipsilateral antegrade or contralateral retrograde
access is obtained in the common femoral artery
using the Seldinger approach. Proximal SFA lesions
are best treated from a contralateral approach, while
distal tibial lesions may be better accessed from an
ipsilateral antegrade femoral approach.
2. An angiogram will be performed sequentially of the
lower extremity of interest prior to intervention.
before any therapy.
3. A guidewire and catheter combination is directed
through the affected artery segment, and contrast is
successful crossing of the lesion.
4. An angioplasty balloon is then directed over the
31.5). Typical angioplasty balloons are mini-
mally compliant and capable of achieving high pres-
D. Suttle and L. R. Wilkins
Stents
If angioplasty yields poor results, greater than 30% residual
stenosis, stenting is the next tool for treatment of hemodynamically signicant infrainguinal atherosclerosis
(Fig.31.6). For TASC A and B lesions, stenting boasts a longer patency rate than PTA alone. Stents used in the leg are
typically self-expanding to combat the massive external
compressive force of the lower extremity musculature. Bare
metal stents are usually made of a nickel-titanium alloy
called nitinol but are prone to failure due to intimal hyperplasia. Stent grafts are typically a nitinol stent lined with fabric
or polymer (e.g., expanded polytetrauoroethylene) and
heparin for longer-term patency [26]. Most stents are delivered to the lesion compressed within a deployment catheter,
which is advanced to the stenotic segment over a guidewire
for deployment. Drug-coated stents, similar to drug-coated
balloons, decrease the formation of intimal hyperplasia.
Recanalization ofChronic Total Occlusions
andSAFARI
lesions receive vessel preparation with a cutting balloon or an atherectomy device.
5. Post-angioplasty angiogram is then performed to
assess for improvement in stenosis as well as for the
disappearance of collateral vessels with a more pat-
6. When applicable, a self-expanding stent is deployed
in the area of stenosis.
Despite a 95% technical success rate for femoropopliteal
stenoses, PTA provides poor overall prevention of re-stenosis [14, 22]. In comparison to surgical bypass, PTA results in
a shorter hospital stay, decreased short-term morbidity, and
is much less expensive [23].
Drug-coated balloons (DCB) are an important advancement in maintaining vessel patency after a successful PTA.
DCBs locally administer an anti-proliferative agent, such as
paclitaxel, to the lesion which reduces intimal hyperplasia
that causes re-stenosis. This is an area of ongoing research,
but the introduction of DCBs demonstrate a reduced rate of
restenosis requiring revascularization [24, 25]. Other variations of PTA exist, including cutting balloons. Cutting balloons have small metal wires or even microblades, which
expand with the balloon during insufation and make incisions in the atheroma to aid expansion and prevent lesion
recoil. These are part of an evolving concept of vessel preparation aimed at allowing a PTA balloon to more completely
open the infrainguinal arteries [14].
As the degree of atherosclerosis worsens, the lumen of a
lower extremity artery may become completely occluded. As
atherosclerosis gradually occludes an artery, the formation of
collateral vessels to supply the distal lower extremity will
increase. These collateral vessels rarely provide sufcient
blood supply, and the patient experiences the symptoms of
PAD including critical ischemia and the threat of tissue loss.
Some chronic total occlusions (CTO) may be traversed in a
true lumen fashion to a distal, patent artery with various
hydrophilic tip guidewires. The utilization of the hydrophilic
tip aids in navigation through “microchannels” found in
CTOs. In addition, there are a number of support catheters
that may be used and offer a hydrophilically coated, exible,
braided shaft with a low-prole tip to increase the chance of
passing through the chronically occluded vessel.
If crossing a heavily calcied, long-segment CTO fails, a
false lumen or subintimal approach may be possible. The
adventitia of an artery receives blood supply from the external vasa vasorum, and the intima and media receive nutrition
internally via intimal diffusion. As chronic atherosclerotic
lesions occlude the distal blood ow, intimal diffusion is
occluded, which decreases the viability of the intimal-medial
interface. This interface, the subintimal space, is prone to
dissection and is the plane used by surgeons during an endarterectomy. When attempting to cross a CTO, the subintimal
space may be entered with a guidewire. This is capitalized
upon by some interventional radiologists, who use the subintimal space to create a false lumen recanalization of an
31 Infrainguinal Disease
349
Fig. 31.5 Percutaneous angioplasty example. A 77-year-old female
with known PAD presenting with left foot osteomyelitis, requiring a
below-the-knee amputation. PTA was indicated to improve blood
ow to the foot in hopes of improved healing status post-amputation.
(a) Long-segment, multifocal left SFA stenoses (arrows). (b –e)
Multiple station insufation of angioplasty balloon along the course
of the stenoses. (f) Angiogram after PTA, with improvement but
residual stenosis. (g) A drug-coated balloon was then used, improving
the patency of the long-segment stenosis over plain old balloon
angioplasty (POBA)
350
D. Suttle and L. R. Wilkins
Fig. 31.6 Stent example. The same 53-year-old male with left leg clau-
dication from Figs.31.1 and 31.2. (a) Angiogram demonstrating distal
left SFA stenosis (arrows). (b) Deployment of stent in the distal segment
occluded artery segment [27, 28]. An antegrade approach to
subintimal recanalization of an occluded arterial segment
requires reentry into the true lumen distal to the occlusion,
which can be extremely challenging.
In cases of difcult true lumen reentry distal to the diseased segment, a reentry device may be used to facilitate
guidewire passage from false lumen back to the true lumen.
There are several reentry devices available which use uoroscopy or intravascular ultrasound to guide a short needle
and then wire being advanced from the false lumen to true
lumen. If advanced reentry techniques fail, retrograde arterial access may be considered to create an entry point into the
subintimal space distal to the diseased segment that later
becomes the reentry point for the antegrade dissection. This
technique is called subintimal arterial ossing with
antegrade- retrograde intervention (SAFARI) and can have
many variants (Fig.31.7).
Key Point
Subintimal arterial ossing with antegrade-retrograde
intervention (SAFARI) refers to creating through and
through wire access in the subintimal space to cross a
chronic total lower extremity arterial occlusion.
of the stenotic area. (c) After balloon dilatation (not shown), there is now
a fully expanded stent. (d) Angiogram after deployment of proximal and
distal stents in the stenotic left SFA demonstrating improved patency
The How To: SAFARI
1. See steps 1–3 above. If the vessel cannot be crossed
in an antegrade fashion, the retrograde approach
may allow the operator to get through and through
access across the lesion.
2. After achieving retrograde access into the popliteal
artery or a tibial artery, intraluminal recanalization
via the retrograde access may occasionally be successful. However, frequently retrograde subintimal
recanalization is necessary.
3. A hydrophilic guidewire and a crossing catheter
may be advantageous for creating the distal entry
into the subintimal space.
4. Frequently, both retrograde and antegrade wires will
often be in the same subintimal plane, and with the
aid of a loop snare, a single through and through
the retrograde wire can often be advanced directly
through the end hole of the antegrade catheter in the
subintimal space without the need for the loop snare.
the wires may be in different, noncommunicating
subintimal spaces, and advanced techniques will be
necessary to achieve a single wire through the
segment to be treated.
5. Once a connection is made between the proximal
true lumen, via the subintimal space across the
diseased artery segment, and the patent distal true
lumen, this single wire is then used as a new track
over which to perform angioplasty and place stents
in the novel lumen [19, 29].
31 Infrainguinal Disease
351
Criteria for performing SAFARI include severe medical
comorbidities causing considerable surgical risk, absence of a
suitable vein conduit, tissue loss in the eld of a potential arterial surgical bypass, and favorable subinimtal recanalization
anatomy including a patent distal tibial artery that supplies a
patent pedal artery [30]. A subintimal approach carries the
risk of arterial injury at the puncture site in the lower leg,
creating and propagating an arterial dissection distally and
excluding branch vessels [19].
Fig. 31.7 SAFARI example. A 60-year-old male with right lower
extremity claudication and a distal SFA chronic total occlusion treated
with SAFARI. (a, b) Right lower extremity angiogram demonstrating
distal SFA occlusion (arrows). (c) Antegrade guidewire (arrow) coiled in
the subintimal space along the proximal stenosis. (d) Retrograde access
was obtained via the posterior tibial artery, and the retrograde guidewire
(thick arrow) is snared (thin arrow) via the antegrade access. (e)
Retrograde wire pulled into the antegrade catheter (arrow). (f) Balloon
angioplasty of stenosis over ossing wire (arrows). (g) Angiogram after
PTA demonstrates improved patency of distal SFA stenosis
352
Key Point
Criteria for performing SAFARI:
• Considerable surgical risk
• Absence of a suitable vein conduit
• Tissue loss in the eld of potential artery surgical
bypass
• Patent distal tibial artery supplying a patent pedal
artery
Acute Limb Ischemia
Acute limb ischemia (ALI) is a true emergency for surgeons
and interventional radiologists, which must be recognized
promptly, as irreversible cell death occurs after 4h of complete occlusion. Patients with ALI should immediately be
placed on heparin infusion to prevent further thrombus propagation. The main deciding factors determining if a patient
should be rushed to the operating room versus angiography
suite depends on the symptoms. Patients with complete
paralysis and sensory loss should be taken for open thrombectomy and surgical exploration with likely concurrent fasciotomies. Patients with muscle weakness but not paralysis
and some sensory decit but not anesthesia are candidates
for endovascular treatment [13]. Techniques for ALI include
pharmacological thrombolysis (direct infusion of tPA),
mechanical thrombectomy with various devices designed to
break down the clot, and aspiration thrombectomy.
Key Point
For patients with acute limb ischemia, therapeutic heparin should be started immediately.
Treatment of infrainguinal peripheral vascular disease is
complex and can involve a variety of disease process, clinical presentations, and treatment options. The interventionalist should be well-versed in the clinical management of and
advanced treatment techniques for this patient population.
References
1. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes
FGR. Inter-society consensus for the management of peripheral
arterial disease (TASC II). JVasc Surg. 2007;45(1):S5–67.
2. Hiatt WR.Medical treatment of peripheral arterial disease and clau-
dication. N Engl JMed. 2001;344:1608–21.
3. Newman AB, Shemanski L, Manolio TA, Cushman M, Mittlemark
M, Polak JF, etal. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The
D. Suttle and L. R. Wilkins
Cardiovascular Health Study Group. Aterioscler Thromb Vasc Biol.
1999;19(3):538–45.
4. Graham IM, Daly LE, Refsum H, Robinson K, Brattstrom LE,
Uelan PM, et al. Plasma homocysteine as a risk factor for vascular disease. The European Concerted Action Project. JAMA.
1997;277(22):1775–81.
5. Singh RB, Mengi SA, Xu YJ, Arneja AS, Dhalla NS.Pathogenesis
of atherosclerosis: a multifactorial process. Exp Clin Cardiol.
2002;7(1):40–53.
6. Stary HC, Chandler B, Dinsmore RE, Fuster V, Glagov S, Insull
W, et al. A denition of advanced types of atherosclerotic lesions
and a histological classication of atherosclerosis. Circulation.
1995;92(5):1355–74.
7. Selvin E, Marinopoulos S, Berkenbilt G, Rami T, Brancati FL,
Powe NR, et al. Meta-analysis: glycosylated hemoglobin and
cardiovascular disease in diabetes mellitus. Ann Intern Med.
2004;141(6):421–31.
8. Stary HC, Blankenhron DH, Chandler AB, Glagov S, Insull W,
Richardson M. A denition of the intima of human arteries and
of its atherosclerosis-prone regions. A report from the Committee
on Vascular Lesions of the Council on Arteriosclerosis, American
Heart Association. Circulation. 1992;85(1):391–405.
9. Hansson G.Inammation, atherosclerosis, and coronary artery disease. N Engl JMed. 2005;325:1685–95.
10. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn
S.Recommended standards for reports dealing with lower extremity ischemia: revised version. JVasc Surg. 2001;33(4):805.
11. Selvin E, Erlinger T. Prevalence of a risk factors for peripheral
arterial disease in the United States: results from the National
Health and Nutrition Examination Survey, 1999–2000. Circulation.
2004;110(6):738–43.
12. Rose GA, Blackburn H.Cardiovascular survey methods. Monogr
Ser World Health Organ. 1968;56:1–188.
13. Kaufman JA, Lee MJ. The requisites: vascular and interventional
radiology. 2nd ed. Philadelphia: Elsevier; 2014.
14. Geschwind JH, Dake MD. Abrams’ angiography: interventional
radiology. 2nd ed. Philadelphia: Wolters Kluwer/Lippincott
Williams & Wilkins Health; 2014.
15. Criqui MH, Fronek A, Klauber MR, Barrett-Conner E, Gabriel
S. The sensitivity, specicity, and predictive value of traditional clinical evaluation of peripheral arterial disease: results
from noninvasive testing in a dened population. Circulation.
1985;71(3):516–22.
16. McKenna M, Wolfson S, Kuller L.The ratio of ankle and arm arterial
pressure as an independent predictor of mortality. Atherosclerosis.
1991;87(2–3):119–28.
17. Carmo GA, Mandil A, Nascimento BR, Arantes BD, Bittencourt
JC, Flaqueto EB.Can we measure the ankle-brachial index using
only a stethoscope? A pilot study. Fam Pr. 2009;26(1):22–6.
18. Investigators THOPES. Effects of an angiotensin-convertingenzyme inhibitor, ramipril, on cardiovascular events in high-risk
patients. N Engl JMed. 2000;342:145–53.
19. Wilkins L, Sabri S.Strategies to approaching lower limb occlusions. Tech Vasc Interv Radiol. 2016;19(2):136–44.
20. Kandarpa K, Machan L. Handbook of interventional radiologic
procedures. 4th ed: Lippincott Williams & Wilkins; Philadelphia
2011.
21. Poirier P, Giles T, Bray G, Hong Y, Stern J, Pi-Sunyer F.Obesity
and cardiovascular disease: pathophysiology, evaluation, and effect
of weight loss. Aterioscler Thromb Vasc Biol. 2006;26:968–76.
22. Muradin G, Bosch J, Stijnen T, Hunink M.Balloon dilation and
stent implantation for treatment of femoropopliteal arterial disease:
meta-analysis. Radiology. 2001;221(1):137–45.
23. Bradbury A.Bypass versus angioplasty in severe ischaemia of the
leg (BASIL): multicentre, randomised controlled trial. Lancet.
2005;366:1925–34.
31 Infrainguinal Disease
353
24. Tepe G, Zeller T, Albrecht T, Heller S, Schwarzwalder U, Beregi
J. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl JMed. 2008;358(7):689–99.
25. Scheinert D, Duda S, Zeller T, Krankenberg H, Ricke J, Bosiers
M. The LEVANT 1 (Lutonix paclitaxel-coated balloon for the
prevention of remoropopliteal restenosis) trial for femoropopliteal revascularization: rst-in-human randomized trial of low-dose
drug-coated balloon versus uncoated balloon angioplasty. JACC
Cardiovasc Interv. 2014;7(1):10–9.
26. Center for Devices and Radiological Health. Recently-Approved
Devices - Endurant II/Endurant IIs Stent Graft System-P100021/
S063 [Internet]. U S Food and Drug Administration Home Page.
Center for Devices and Radiological Health; [cited 2018Mar23].
Available from: https://www.fda.gov/medicaldevices/product-
sandmedicalprocedures/deviceapprovalsandclearances/recentlyapproveddevices/ucm581234.htm.
27. Reekers J, Bolia A.Percutaneous intentional extraluminal (subintimal)
recanalization: how to do it yourself. Eur JRadiol. 1998;28:192–8.
28. Sabri S, Angle J, Spinosa D, Matsumoto ARE. Regarding the
“SAFARI” technique: a word of caution (letter to the editor).
Cardiovasc Intervent Radiol. 2010;33:1064–5.
29. Hendricks N, Sabri S.Subintimal arterial ossing with antegraderetrograde intervention (SAFARI) and retrograde access for critical
limb ischemia. Tech Vasc Interv Radiol. 2014;17(3):203–10.
30. Spinosa D, Harthun N, Bissonette E. Subintimal arterial ossing
with antegrade-retrograde intervention (SAFARI) for subintimal
recanalization to treat chronic critical limb ischemia. JVasc Interv
Radiol. 2005;16:37–44.
Part VIII
Trauma