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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3745_Библиотеки_им_академика_М_И_Перельмана
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Angioplasty for Critical Arterial Stenosis 145
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leaving a catheter in the thrombus and starting thrombolysis; however, this decision
is at the surgeon’s discretion and depends on his/her experience. The reopened SFA
might be sufficient for appropriate perfusion of the lower leg.
So what evidence exists that PTA is the correct treatment for this case? Level I
evidence does not exist, but the consensus is that short lesions of less than 7 cm
should be treated in this way [6]. The indication should be the same as for open
surgery, namely critical limb ischaemia but also disabling claudication, provided
that the patient’s quality of life would be very much improved by an increased possibility to walk.
Whether PTA is superior to exercise alone is still under debate [7, 8]. There is,
however, no doubt that PTA is more accepted for iliac lesions than for SFA lesions
in cases of intermittent claudication. If one accepts PTA, then it has to be clear that
recurrence of symptoms is not uncommon, and that the duration of the effect of
treatment is variable. Stents may be deployed following iliac angioplasty but are less
effective in SFA angioplasty. Improved results are claimed by those who do subintimal angioplasty. The use of stents in the SFA should be reserved at present as a
rescue procedure in cases of suboptimal dilation causing dissection or any other
damage to the vessel. Controlled studies are needed to define the indications of
stenting, in particular with the new generation of drug diluting stents, in the
management of peripheral vascular disease.
Complications of PTA include bleeding at the puncture site (about 2 per cent),
pseudoaneurysms (0.7 per cent) [9], local vessel damage (see above), and vessel
rupture (very infrequent). Bleeding at the puncture site is normally treated with
compression, but surgery may be required. Likewise, pseudoaneurysms can be
treated by ultrasound-guided compression or thrombin injection. As described,
local damage to the vessel with dissection may be treated with a stent; local bleeding
caused by rupture commonly does not require any treatment other than careful
observation to avoid compartment syndrome due to an expanding haematoma.
When following up patients after PTA, duplex examination can be of value as it
can find restenosis long before the ankle blood pressure is reduced, although ABPI
should be measured regularly. Other investigations are not required, should no
symptoms reappear that demand treatment. [Q4: B, D]
All forms on continuing exercise are of importance for all patients after treatment
for PAOD and no detrimental effects of cycling should be anticipated; antiplatelet
drugs should be administered for secondary prevention of thrombotic events at the
treatment site but mainly for coronary and cerebrovascular thrombotic events.
Warfarin is not indicated. [Q5: B, E]
References
1. Dormandy J, Mahir M, Ascady G, Balsano F, De Leeuw P, Blombery P, et al. Fate of the patient with
chronic leg ischaemia. J Cardiovasc Surg 1989;30:50–57
2. Jelnes R, Gardstang O, Jensen HK, Baekgaard N, Tonnesen KH, Schroeder T. Fate in intermittent clau-
dication: outcome and risk factors. BMJ 1986;293:1137–40
3. Rosenbloom MS, Flanigan DP, Schuler JJ. Risk factors affecting the natural history of intermittent
claudication. Arch Surg 1988;123:867–70.
4. Second European Consensus Document on Chronic Critical Leg Ischemia. Circulation 1991;84 (Suppl
4).
5. Rutherford RB, Baker JD, Ernst C, Jonston KW, Porter JM, Ahn S, Jones DN. Recommended standards
for reports dealing with lower extremity ischemia: revised version: J Vasc Surg 1997;26:517–38.
146 Vascular Surgery
6. Management of peripheral arterial occlusive disease. Trans-Atlantic Intersociety Consensus document
(TASC). J Vasc Surg 2000;31 (Part 2):S1–S296.
7. Norgren L. Is balloon angioplasty indicated for intermittent claudication? – Yes. In: Greenhalgh RM,
editor. Indications in vascular and endovascular surgery. London: WB Saunders, 1998;285–92.
8. Bradbury A. Is balloon angioplasty indicated for intermittent claudication? – No. In: Greenhalgh RM,
editor. Indications in vascular and endovascular surgery. London: WB Saunders, 1998;293.
9. Criado FJ, Abdul-Khoudoud O, Twena M, Clark NS, Patten P. Outpatient endovascular intervention: is
it safe? J Endovasc Surg 1998;5:236–9.
16. Lower Limb Claudication due to Iliac
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Artery Occlusive Disease
Fabien Koskas and Marcus J. Brooks
A 63-year-old hypertensive man presented in 1990 with a history of pain developing in his left calf and thigh after walking 100 metres. During the preceding
3 months, following the introduction of a beta-blocker for newly diagnosed
hypertension, the distance he could walk at a “normal” pace had reduced from
200 metres. The pain ceased almost immediately after stopping walking and
appeared again after the same interval. A systemic enquiry was unremarkable.
He was noted to be an active and life-long heavy smoker. Clinical examination
revealed a diminished left femoral pulse and absent left popliteal and pedal
pulses. The abdominal aorta and right leg pulses were normal. No bruits were
audible in the abdomen or groins.
Question 1
Which of the following would be part of your initial management of this patient?
A. Smoking cessation advice.
B. Enrolment of the patient in a supervised exercise programme.
C. Stopping the beta-blocker.
D. A prescription for warfarin.
E. A prescription for aspirin.
Simple advice was given on the importance of exercise as there was no supervised
exercise programme available. The patient managed to stop smoking completely.
He returned to the clinic after 3 months and his symptoms had not improved. As
the patient was shortly to be retiring and was an enthusiastic hunter he was very
keen for any intervention that might relieve his claudication.
147
148 Vascular Surgery
Question 2
How would you proceed with your management now he has returned?
A. No further intervention.
B. Drug treatment with cilostazol.
C. Obtain arterial imaging to better define the lesion.
Question 3
Which of the following is not an appropriate first line imaging modality?
A. Duplex scan.
B. Contrast-enhanced CT scan (CTA).
C. Contrast-enhanced magnetic resonance angiography (MRA).
D. Digital subtraction contrast angiogram (IADSA).
The patient underwent an arterial duplex scan. This scan showed a significant
stenosis at the left internal iliac origin and a short but tight stenosis of the proximal
external iliac artery. The contralateral iliac system was found to be free from
significant disease, as were the femoral, popliteal and crural arteries. Subsequent
angiographic images are shown in Fig. 16.1.
Question 4
Which of the following would you consider as possible interventions?
A. Aorto-bifemoral bypass graft.
B. Left aorto-uni-iliac bypass graft.
C. Right femoral to left femoral cross-over graft.
D. Percutaneous transluminal angioplasty via a right femoral puncture.
E. Percutaneous transluminal angioplasty via a left femoral puncture.
A percutaneous transluminal angioplasty was performed from the left groin
using a 7-mm balloon. The left leg pulses were restored by the procedure. The
patient noticed that his claudication disappeared.
Question 5
Which of the following statements describe the optimal follow-up for this patient?
A. Low-dose subcutaneous low-molecular-weight heparin for 3 months.
Lower Limb Claudication due to Iliac Artery Occlusive Disease 149
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a
c
Fig. 16.1. Images from the digital subtraction angiogram showing a the renal arteries, infrarenal aorta and
iliac bifurcation, b stenotic lesions at the origin of the left internal iliac artery and in the left external iliac artery,
and c an oblique projection of the left iliac system.
b
150 Vascular Surgery
B. The patient is seen regularly, for review of his claudication and control of his
risk factors.
C. Serial duplex scanning to detect recurrent stenosis before symptoms occur.
D. The patient is discharged from follow-up.
Eleven years later the patient returned complaining of recent onset of erectile
dysfunction and the return of his left calf claudication.
Question 6
What is the likely aetiology of this man’s erectile dysfunction?
In the intervening 10 years the patient had resumed smoking and had undergone
a coronary artery bypass graft for unstable angina. Two years following the bypass
his angina had recurred. A coronary angiogram showed that two of three vein grafts
had occluded, and that his left ventricle function was poor (28 percent ejection fraction). On examination his left femoral pulse was weak, the distal pulses were absent
in the left leg and a soft bruit was heard over the right femoral artery. The patient
insisted on being relieved from his symptoms “no matter the risks” as he had
married a woman much younger than him. Another angiogram was requested, one
image from which is shown in Fig. 16.2. The distal run-off (not shown) was preserved in both legs.
Fig 16.2. Angiogram performed for investigation of the patient’s erectile dysfunction and recurrence of left calf
intermittent claudication.
Lower Limb Claudication due to Iliac Artery Occlusive Disease 151
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Question 7
Which of the following is now the preferred intervention?
A. Aorto-bifemoral bypass graft with revascularisation of both internal iliac
arteries.
B. Left aorto-uni-iliac bypass graft with revascularisation of the left internal iliac.
C. Right femoral to left femoral cross-over graft.
D. Percutaneous transluminal angioplasty.
E. No intervention – claudication and impotence are a good way of protecting the
heart.
A percutaneous approach was used; a hydrophilic guidewire passed easily
through the lesion and both the external and internal iliac lesions were treated
endovascularly (Fig. 16.3).
Commentary
The majority of patients with peripheral vascular disease smoke [1]. Cessation of
smoking slows the rate of progression of peripheral vascular disease and reduces
the risk of cardiac morbidity and mortality [2]. The prescription of nicotine replacement therapy is of benefit in patients who find it difficult to quit [3]. The benefit of
exercise for relieving the symptoms of intermittent claudication has long been
recognised [4]. The type and frequency of exercise to yield maximum benefit has
now been examined in a systematic review and Cochrane Collaboration Overview;
advice alone is of little benefit but supervised exercise programmes (achieving
maximal walking distance for at least 30 minutes three times a week) can achieve a
150 percent increase in walking distance or 6-minute increase in walking time [5, 6].
A systematic review failed to show any association between beta-blockers and worsening claudication [7]. If the beta-blocker is stopped another antihypertensive
agent, such as a calcium channel blocker or ACE inhibitor, should be substituted for
control of hypertension, as treating hypertension reduces the stroke risk by 38
percent, cardiovascular risk by 14 percent and peripheral vascular events by 14
percent [8]. A systematic review by the Anti-platelet Trialists Collaboration has
proven the benefit of 75–1500 mg aspirin daily in achieving a 25 percent reduction
in the risk of death, stroke or myocardial infarction [9]. A post-hoc subgroup analysis of patients with peripheral vascular disease in the CAPRIE trial showed additional benefit for clopidogrel [10]. The additional benefit is small (196 patients on
clopidogrel to prevent one death) and not justified except for the 20 percent of
patients who are aspirin intolerant. There is no evidence of benefit from warfarin
[11]. It is also important to start the patient on statin therapy as this intervention
has been shown to achieve an equivalent reduction in morbidity and mortality to
aspirin [12, 13]. [Q1: A, B, E]
The patient returns having modified his risk factors and is no better. His claudication is affecting his quality of life. The options for management are persistence
with unsupervised exercise, drug treatment or intervention. Cilostazol is the only
152 Vascular Surgery
a
c
Fig 16.3. Images from the second procedure showing a passage of a hydrophilic guidewire across the occluded
external iliac artery, b an excellent technical result from angioplasty with stent placement in the external iliac
artery with the wire now positioned in the internal iliac artery and c a completion angiogram.
b
Lower Limb Claudication due to Iliac Artery Occlusive Disease 153
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drug shown to be effective at relieving the symptoms of intermittent claudication in
a small randomised trial [14, 15]. However, it is expensive and the effect is shortlived. Intervention can only be considered once the anatomy of the underlying
stenosis is known. As the presenting symptom is intermittent claudication and the
patient has a weak left femoral pulse with normal right leg pulses we suspect a
single level left iliac stenosis. It was decided to image the lesion. [Q2: C, (B)]
The optimal imaging of aortoiliac lesions is dependent on the facilities available.
It is preferable to first obtain non-invasive images to allow the approach to a lesion
to be planned, ensure the appropriate equipment is available and obtain the appropriate patient consent . Duplex scanning has become a useful tool for non invasive
evaluation of aortoiliac occlusive disease [16]. However, duplex in the aortoiliac
segment is highly dependent on patient’s body habitus and experience of the operator. A helical multi-detector row (32 or 64 detectors) CT scanner can provide highquality cross-sectional images of the aorta, iliac arteries and even arteries down to
the feet. CT scans have the advantage to the surgeon of familiarity and show
calcified vessel walls. The disadvantages of CTA are the risk of contrast-induced
nephropathy, patient exposure to ionising radiation and the time it takes to reformat the images [17, 18]. Contrast-enhanced magnetic resonance angiography
(MRA) can also image the aortoiliac segment down to the feet. It is the investigation
of choice in patients at risk of contrast-induced renal impairment. In a comparison
of CTA and MRA in imaging the aorta and iliac segments, sensitivity and specificity
for the detection of lesions were equivalent. CTA took longer to reformat and
report; a greater proportion of patients expressed a preference for CTA [19]. MRA is
contraindicated in patients with pacemakers and ferromagnetic intracranial
aneurysm clips. Intra-arterial digital subtraction angiography now has a limited
diagnostic role in the aortoiliac segment. Angiography is invasive and is only performed if artefacts from previous implants (i.e. stainless steel stents) degrade threedimensional imaging, if direct pressure measurements across a stenosis are
required or, as in this patient, as the first stage of an invasive procedure following
non-invasive imaging. [Q3: D]
The left internal iliac origin and mid-third external iliac artery lesions are
TransAtlantic Inter-Society Consensus (TASC) type A lesions [20]. The TASC consensus on the management of type A aortoiliac lesions (Recommendation 32) was for
endovascular intervention. Surgical options, endarterectomy or bypass, are reserved
for longer stenoses (5–10 cm) or occlusions [20]. The reported primary technical
success of angioplasty of type A lesions is 98–99 percent with 60–80 percent patency at
5 years [21]. The 5-year patency of open procedures is slightly better, 90 percent for
aorto-bifemoral bypass, but the patient is exposed to the risks of death (2–3 pre cent),
erectile dysfunction and graft infection [22]. It is a matter of personal preference
whether a left or right percutaneous approach is used for the angioplasty as the lesion
is mid-way between the aortic bifurcation and inguinal ligament. [Q4: D or E]
The optimal management of patients following angioplasty has not been evaluated in randomised control trials. The risks to the artery are thrombosis, myointimal hyperplasia and disease progression. All patients should already be on an
antiplatelet agent. Patients are formally heparinised during the procedure and for
this short stenosis this is probably adequate. There is no evidence that postprocedure low-molecular-weight heparin, or for that matter any pharmacological
agent (e.g. ticlopidine), is of benefit. Routine graft surveillance has been shown
to improve the secondary patency of infra-inguinal vein bypass grafts [23].
Surveillance has not been evaluated following iliac angioplasty. As myointimal
154 Vascular Surgery
hyperplasia and disease progression both occur, it appears prudent, if not mandatory, to follow up patients. This can be done using clinical examination, arterial
duplex or ankle brachial pressure index (ABPI) measurement. Clinical follow-up is
cost-effective and is a good way of enforcing a tight control of risk factors. [Q5: B]
Erectile dysfunction in this setting is probably due to arterial insufficiency resulting from progression of bilateral iliac occlusive disease as the patient has a new
bruit in the right groin. The association of erectile dysfunction with aortoiliac occlusive disease was first described in 1814 by Robert Graham [24]. However, it was
Rene Leriche who in 1940 in Paris operated on a 29-year-old truck driver “who for
two years had been suffering from claudicatio intermittens with severe cramps in
the leg musculature already after a few hundred meters of walking, and cramp pains
also at night. The last weeks before the operation he complained of not being able to
complete an intercourse, as both erection and ejaculation was disturbed” [25]. [Q6:
Leriche syndrome]
The patient has suffered disease progression in the intervening years. He has
developed a very tight stenosis of the left internal iliac artery, a stenosis or the right
internal iliac artery origin and complete occlusion of the left external iliac. The left
external iliac lesion is classified as a TASC type C lesion [20]. The consensus in 1990,
when the TASC guidelines were drawn up, was that definitive recommendations on
how to treat such lesions must await more convincing evidence. This situation has
not changed. The risks of open aortoiliac bypass surgery and endarterectomy have
already been discussed. Remote iliac endarterectomy using Moll ring strippers
avoids an abdominal approach and pelvic dissection, has good published technical
success rates (88–92 percent), and 3-year patency just below that of open
endarterectomy (60 percent) [26, 27]. A potential development for the future is
laparoscopic aortoiliac surgery [28]. In this patient a femoral-femoral cross-over
graft is not advisable because contralateral lesions may impair the graft inflow and
because this procedure would not address the internal iliac stenoses. Had the
cardiac antecedents not been present, direct bilateral surgical antegrade revascularization of the lower limbs and one or both internal iliac arteries would have been an
excellent solution. However, in the context of unreconstructable coronary artery
disease and poor left ventricular function, such a solution is too invasive and carries
the risk of potentially lethal cardiac morbidity. On the other hand, surgical abstention, although not without justification, seems exaggerated because quality of life is
often as important as its length among middle-aged and aged patients. [Q7: D]
Stenting is generally reserved for the management of lesions with a high risk of
primary failure (i.e. eccentric calcified plaque), primary failure (residual stenosis
greater than 50 percent or greater than 10 mm Hg pressure gradient), dissection or
distal embolisation [29]. In this patient, stents were placed because of the recurrent
occlusion of the external iliac and residual stenosis in the internal iliac artery. The
patient recovered from his claudication, as well as his impotence, without any
significant cardiac morbidity and is still doing well 4 months after the procedure.
References
1. Kannel WB, Shurtleff D. The Framingham Study. Cigarettes and the development of intermittent
claudication. Geriatrics 1973;28:61–8.
2. Mathieson FR, Larsen EE, Wulff M. Some factors influencing the spontaneous course of arterial vascular insufficiency. Acta Chir Scand 1970;136:303–8.
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