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74 B. M. Hoppenfeld and J. Cynamon
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A–E
F–I
FIGURE 7-4. An 83-year-old man with diabetes presented with a nonhealing ulcer of the right heel. (A) A short-segment
occlusion of the popliteal artery is identified on the initial arteriogram performed via the left common femoral artery. A right
common femoral antegrade puncture is performed to treat the lesion, and this digital image of the lesion is acquired. (B)
Arteriogram of the distal runoff demonstrates occlusions of the midportion of the anterior tibial and of the posterior tibial arteries.
The tibial–peroneal trunk is patent, and there is mild disease at the origin of the peroneal artery. (C) Angioplasty of the popliteal
lesion is performed with a 4 mm ⫻ 4 cm balloon. (D) The balloon is brought to full profile. (E) Postangioplasty angiogram
demonstrates resolution of the popliteal occlusion, but the distal runoff appears obstructed. (F) Occlusion of the anterior tibial
artery and tibial–peroneal trunk is noted in the runoff evaluation. A 6 Fr guiding catheter is advanced over the guidewire to the
site of occlusion. (G) Aspiration thromboembolectomy is performed with the guiding catheter, and the embolus is removed. The
catheter and aspirated embolus are displayed on the gauze pad. (H and I) Postaspiration angiogram demonstrates recovery of
the original runoff.
lesion, the bypass may be compromised as a result of
inadequate flow. Iliac angioplasty and stent placement
can be performed around the aortic bifurcation using
the puncture site of the diagnostic arteriogram. In many
circumstances, we choose to puncture the ipsilateral common femoral artery in a retrograde fashion. This ap-
proach allows for simultaneous arterial pressure measurements above and below the lesion and facilitates accurate
straight-line stent placement at the origin of the common
iliac artery, if necessary (Fig. 7-1).
All interventions should be performed through a vas-
cular sheath. The sheath usually facilitates the interven-
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Vascular Recanalization Techniques 75
G–K
FIGURE 7-5. A 68-year-old man presented with new-onset rest pain in the right lower extremity. (A) Diagnostic angiogram is
performed from the right common femoral artery, demonstrating occlusion of the left popliteal artery. (B) Significant three-vessel
tibial disease is noted with reconstitution of the distal anterior tibial artery. (C) An up and over Balkin contralateral 5.5 Fr sheath
(Cook Group Company) was advanced into the external iliac artery. A 5 Fr Berenstein catheter (Angiodynamics) was advanced
over a Bentson guidewire (Angiodynamics, Inc.) into the popliteal artery, and a Possis Angiojet device (Possis Medical) was
passed over a V-18 control wire (Boston Scientific) across the occlusion. (D) Closeup of the Possis Angiojet removing thrombus.
(E) Post-Possis angiogram demonstrates a channel and underlying lesions. At this point, the patient became asymptomatic. Two
hours of thrombolysis with rt-PA was performed at 2 mg/hour drip into the superficial femoral artery to dissolve any residual clot
that may not have been removed by the Possis device. (F) Significant improvement was noted following thrombolysis. (G)An
angioplasty of the stenotic lesion was performed with a 5 mm ⫻ 4 cm balloon. (H) Postangioplasty angiogram demonstrates a
good result. (I) The infrapopliteal angiogram is unchanged. (J) There is reconstitution of the distal anterior tibial and dorsalis
pedis arteries. (K) Photograph of the Possis Angiojet’s Halo catheter.
tion by allowing for rapid catheter exchange, easier postprocedure angiographic evaluation, and decreased patient discomfort in the groin; it is associated with a lower
incidence of complications. All patients are routinely
pretreated with aspirin as an antiplatelet agent. Although many physicians use intraprocedural anticoagulation with heparin, its value is unconfirmed, and excessive use of heparin may lead to a higher incidence
of local complications such as hematomas and
pseudoaneurysms. With the current advances of endoluminal closure devices, full anticoagulation is less prob-
lematic. Ideally, tight stenotic lesions should be crossed
using road mapping. The best guidewire catheter combination to cross the stenosis depends on the lesion and
the operator.
Long lesions, external iliac arter y lesions, and occlusions also can be treated. The optimal percutaneous
therapy for iliac occlusions has not yet been determined.
These lesions have been treated with initial lysis and
subsequent angioplasty or stenting of the underlying lesions. Other successful treatments include primary stent-
12–15
ing of iliac occlusions
(Fig. 7-2). The response to
76 B. M. Hoppenfeld and J. Cynamon
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A
C–E
FIGURE 7-6. A 57-year-old woman with metastatic cervical cancer, postradiation therapy, presented with claudication progress-
ing to rest pain in the right lower extremity. (A) Diagnostic arteriogram performed from the right common femoral artery
demonstrates a significant lesion across the right external iliac artery. A significant pressure gradient is identified. (B)A7⫻
60 mm Smart Stent (Cordis, Johnson & Johnson Corp.) is deployed across the lesion. Following angioplasty, rupture of the iliac
artery is suspected from the patient’s continued pain and confirmed with angiography. (C) The balloon is inflated across the
rupture to control the bleeding. (D) Bleeding continues despite prolonged balloon inflation. (E) A covered stent is deployed, the
rupture is controlled (as demonstrated in the poststenting angiogram), and the iliac lesion is resolved.
balloon angioplasty of longer lesions is often less than
ideal. Suboptimal angioplasty or an occlusive dissection
is not uncommon; therefore, many interventional radiologists would recommend stenting these lesions primarily (Fig. 7-3). A balloon-expandable stent (e.g., PalmazSchatz, Cordis, Johnson & Johnson Corp., New
Brunswick, NJ, U.S.A.) (see Fig. 7-1B) an IntraStent (Intratherapeutics, St. Paul, MN, U.S.A.) (see Fig. 7-3) or a
self-expanding stent such as the Wallstent (Boston Scientific Corp., San Ramon, CA, U.S.A) or Smart Stent
(see Fig. 7-17D) (Cordis, Johnson & Johnson Corp., New
Brunswick, NJ, U.S.A.) (see Fig. 7-17D) can be placed.
Suboptimal angioplasty of ideal lesions also can be managed by placing a stent (see Fig. 7-1). After intervention,
pressures should be obtained again to assess hemodynamically the adequacy of the intervention.
11,16–18
Most complications of angioplasty can be managed
nonoperatively. The most common complication is a hematoma, usually self-limited at the puncture site.
Pseudoaneurysms can be treated definitively by using
ultrasound-guided compression or percutaneous thrombin injection. In situ thrombosis or distal embolization
during or after angioplasty can be treated with intraarterial thrombolytics, with suction thromboembolectomy using a guiding catheter (Fig. 7-4), or with the Possis
Angiojet device (Possis Medical, Minneapolis, MN,
U.S.A.). Obstructing flaps can be stented. Iliac rupture is
a feared complication because these patients may require
surgery to prevent exsanguination. Iliac rupture is suggested by the presence of continued pain after the
angioplasty balloon is deflated and the presence of free
extravasation of contrast after angioplasty. The angioplasty balloon should be immediately reinflated across
the lesion to tamponade the rupture. The patient then
can be considered for transfer to the operating room for
repair of the vessel; alternatively, a covered stent (if available) can be delivered via the femoral access to exclude
the rupture (Fig. 7-6).
B
Vascular Recanalization Techniques 77
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A–D
FIGURE 7-7. A 70-year-old woman, a smoker with diabetes, presented with a nonhealing ulcer of the left foot. (A) Long-leg
cut-film film angiogram demonstrates a steep bifurcation of the aorta. (B) Mild to moderate disease is present in the superficial
femoral artery and popliteal artery, with a severe (99%) stenosis of the proximal popliteal artery in the adductor canal. (C) Despite
the steep bifurcation, a second puncture is avoided, and an up and over Balkin contralateral 5.5 Fr sheath (Cook Group
Company) was advanced into the left common iliac artery. A guidewire is advanced beyond the lesion, anda5mm⫻ 3cm
balloon angioplasty is performed. (D) Postdilatation angiogram demonstrates an adequate result.
■ Superficial Femoral and Popliteal Artery
Intervention
Stenoses or occlusions of the superficial femoral arter y
and popliteal arter y up to 10 cm long are considered
amenable to balloon angioplasty. These lesions can be
approached from the contralateral extremity by using the
common femoral artery access created during the diagnostic arteriogram (Fig. 7-7). Using an “over-the-corner”
sheath markedly facilitates the advancement of balloon
catheters across lesions using the contralateral approach.
Alternatively, an antegrade puncture can be performed. An antegrade puncture can be technically challenging, especially in obese patients. Again, one must be
careful to enter the common femoral artery (CFA) at the
midfemoral head, below the inguinal ligament and above
its bifurcation (Fig. 7-8). The guidewire then must be
selectively advanced into the superficial femoral artery
(SFA). Several techniques have been developed to redirect the wire that preferentially advances into the profunda femoral artery (PFA): After documenting that the
entry point is into the CFA, the needle can be redirected
to the contralateral wall and the wire readvanced; alternatively, the floppy tip of a moveable core wire can be
advanced into the profunda and allowed to herniate into
the SFA. Another method is to exchange the needle for
a directional catheter and retract it under fluoroscopy to
redirect a wire into the SFA. A fourth method is to exchange the needle for a 4 French dilator, place a 0.018inch guidewire into the PFA, and withdraw the dilator
into the CFA; then, using road mapping, a second 0.018inch guidewire is advanced through the dilator, directing
it into the SFA; finally, a dilator with a sidehole proximal
to the endhole (Cope-Saddekni SFA Access dilator, Cook
Group, Bloomington, IN, U.S.A.) can be advanced into
the PFA and retracted until a wire can be advanced
through the sidehole and into the SFA. After the wire is
in place in the SFA, a vascular sheath is introduced. Most
physicians anticoagulate patients during the procedure
to prevent thrombus formation resulting from partially
obstructed flow, catheter manipulations, or balloon inflation.
Using road mapping, a directional catheter and floppy
guidewire (the choice of guidewire and catheter is operator and lesion dependent), the lesion is crossed. The
catheter then is exchanged for a balloon of appropriate
size and length. Alternatively, the angioplasty balloon can
be used with an appropriate guidewire primarily to cross
the lesion, thereby saving a catheter exchange. The
postangioplasty result is evaluated by a repeat angiogram
while maintaining a guidewire across the angioplasty site.
Less than a 30% residual stenosis without embolic complication constitutes a successful result. Embolic complications can be managed with thrombolysis or suction
aspiration (see Fig. 7-4). If there is an obstructing flap or
a residual stenosis, a prolonged dilatation can be attempted to improve this initial result or to tack down the
flap. Alternatively, stents can be used to bridge obstructing flaps postangioplasty; however, the long-term patency
of femoropopliteal stents is not well documented.
78 B. M. Hoppenfeld and J. Cynamon
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A–C
D–F
FIGURE 7-8. (A) Diagram of antegrade puncture of the common femoral artery over the midfemoral head. (B) Demonstration
of redirection of the needle tip by injecting contrast to identify the superficial femoral artery from the profunda. (C) Demonstration
of redirection of the guidewire into the superficial femoral artery (SFA) through the needle. (D) Demonstration of redirection of
the guidewire by herniation of the wire into the SFA. (E) Demonstration of using a 4 Fr dilator with two 0.018-inch guidewires,
one in the profunda, while the dilator is retracted and the second wire is passed down the SFA. (F) Demonstration of Saddekni
dilator (Cope-Saddekni SFA access dilator: Cook Group) redirecting the wire into the SFA.
A–D
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E–H
FIGURE 7-9. An 85-year-old diabetic man presented with a nonhealing right heel ulcer. (A) Diagnostic angiogram is performed
from the left common femoral artery demonstrating a long right popliteal artery occlusion. Note the large collateral immediately
above the popliteal occlusion. (B) Note the reconstitution of the distal popliteal at the trifurcation. (C) A 5 Fr Berenstein catheter
is brought to the “nubbin” of the lesion and a Bentson guidewire is used to enter the subintimal plane of the vessel. The catheter
and guidewire are advanced into the subintimal plane. (D) The catheter and wire reenter into the true lumen of the popliteal artery
and an angiogram is performed to demonstrate reentry. (E)A4mm⫻ 10 cm balloon angioplasty is performed. (F–H) Post
angioplasty arteriogram demonstrates the smooth subintimal space and the straight-line flow into the tibial vessels, continuing
to the foot.
Although long SFA lesions typically are not treated
18a
percutaneously, Bolia
described subintimal angioplasty as an alternative to bypass or routine angioplasty.
This procedure requires a subintimal passage of a
guidewire at the proximal end of a lesion and reentry
into the native lumen at or distal to the diseased segment (Fig. 7-9). The subintimal space is usually a
smooth, nonthrombogenic surface. If the inflow and
outflow are sufficient, a good long-term response can
be expected. This work needs to be corroborated by
other investigators.
■ Infrapopliteal Angioplasty
The availability of low-profile balloon catheters that can
be delivered through a 4 or 5 Fr sheath and thinner,
steerable guidewires has made tibial angioplasty technically feasible; the results have shown it to be quite dura-
19
ble.
The indications for infrapopliteal angioplasty are
primarily limb salvage. These patients require straightline flow to the foot by at least one of the three tibial
vessels. The challenge in these patients is to reestablish
straight-line flow.
80 B. M. Hoppenfeld and J. Cynamon
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A–D
FIGURE 7-10. A 78-year-old woman with a history of posterior wall myocardial infarction, status post four-vessel coronary artery
bypass graft with 25% ejection fraction presented with a 2-month history of a nonhealing vein donor site in the left lower extremity.
(A) Diagnostic angiogram is performed from the right common femoral artery. Although it is mildly diseased, there are no focal
stenoses identified above the left popliteal artery. Occlusion of the left anterior tibial and posterior tibial arteries with severely
diseased peroneal artery is identified. (B) An antegrade puncture of the left common femoral artery is performed, and a 4 Fr
sheath is advanced into the superficial femoral artery SFA. A V-18 control wire (Boston Scientific) is advanced into the peroneal
artery and across the multiple peroneal stenoses. (C) A low-profile 2.5 mm ⫻ 4 cm balloon is used to angioplasty the peroneal
stenoses, as well as the tibial–peroneal trunk. (D) Postangioplasty angiogram demonstrates significantly improved distal runoff.
Infrapopliteal angioplasty generally should be performed by an antegrade puncture of the ipsilateral CFA.
Our patients are routinely given an antiplatelet agent
(aspirin) prior to the angioplasty. The patient should be
anticoagulated systemically throughout the entire procedure to prevent clot formation in the tibial vessels during
catheter manipulation and prolonged angioplasty. The
lesions should be crossed using road mapping. A 0.018inch platinum-tipped guidewire or glidewire (Terumo,
Tokyo, Japan) should be used to cross the stenosis or
occlusions, allowing a low-profile angioplasty balloon to
be used (Fig. 7-10). As opposed to femoral angioplasty,
where the use of vasodilators may be helpful but nonessential, vasodilators in the tibial distribution are extremely helpful to avoid spasm in these small vessels. We
routinely use 100 to 200 lg of nitroglycerin in bolus
form.
The presence of long SFA occlusive disease requiring
bypass and focal tibial lesions is not uncommon. An approach to be considered in this group of patients is an
above knee bypass and an intraoperative angioplasty of
the tibial vessels. This combined approach can save limbs
while preserving the vein and reducing the morbidity
associated with a distal bypass.
■ Renal Artery Angioplasty
The workup for patients with suspected renal vascular hypertension or progressiveazotemia is discussed elsewhere.
If a renal artery stenosis is suspected, an arteriogram
should be performed. Typically, the arteriogram is performed from a femoral approach with anteroposterior
(AP) and multiple obliques so as to evaluate adequately
the osteal segment and the moreperipheral segments and
intrarenal segments of the renal arteries. If a renal artery
stenosis is identified, a renal angioplasty should be consid-
20–30
ered.
Before embarking on any renal intervention, a
bailout option should beidentified sothat ifthere isa noncorrectable injury to the renal artery, an appropriate surgical repair can be performed. Because many surgeons
choose to bypass the renal artery off the celiac axis, it
would be prudent to perform either alateral aortogram to
evaluate the origin of the celiac axis or to measure pressures in the celiac arter y to reveal any hemodynamically
significant proximal celiac artery stenosis. Judicious useof
vasodilators, such as intraarterial nitroglycerin, should be
used throughout the case to limit or prevent the degree of
spasm in the renal arteries. The patient should be fully
heparinized throughout the procedure.
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A–C
D–F
FIGURE 7-11. A 32-year-old woman presented with persistent hypertension, unable to control on three medications. (A) Flush
aortogram is performed through an Omni Flush catheter (Angiodynamics) from the right common femoral approach. Bilateral renal
artery lesions are identified, consistent with fibromuscular dysplasia. (B) A selective right renal angiogram is performed using a
Sos Omni Selective catheter (Angiodynamics), demonstrating fibromuscular dysplasia (FMD) throughout the renal artery. (C)A
marker sheath is advanced to the level of the renal orifices. AV-18 control wire (Boston Scientific) is advanced into the renal artery
and across the multiple lesions. Angioplasty is performed witha5mm⫻ 2 cm balloon across the lesions. (D) After achieving good
results in the right renal artery, a 5 Fr Sos Omni selective catheter is advanced into the left renal orifice, and a selective angiogram
is performed. Multiple distal lesions are identified consistent with FMD disease. (E) The V-18 control wire is advanced across the
left renal artery lesions, and angioplasty is again performed with the 5 mm ⫻ 3 cm balloon. (F) Postbilateral angioplasty angiogram
demonstrates excellent results in both renal arteries.
81
The existing diagnostic catheter should be changed to
a 5 Fr sheath. Before the renal artery evaluation is begun,
the appropriate oblique that demonstrates the renal artery orifice must be determined. This may involve cranial–caudal angulation in addition to lateral rotation in a
tortuous aorta. We choose to catheterize the renal arteries
using a short sidewinder catheter such as a Sos-Omni
catheter (Angiodynamics, Queensbury, NY, U.S.A.) and a
platinum-tipped, tapered guidewire, such as a TAD II
(Mallinckrodt, St. Louis, MO, U.S.A.). After the wire
crosses the lesion, the catheter is pulled down, which
causes the tip to advance beyond the lesion. The
guidewire is advanced farther into the renal artery.
The catheter is removed, leaving the guidewire in place.
The balloon is advanced over the guidewire, and the dilatation can be performed (Fig. 7-11). The patient should
be fully anticoagulated during the entire procedure. A
postangioplasty angiogram must be performed while the
guidewire is still in place. This can be done via a second 3
or 4 Fr catheter in the same sheath. Alternatively, a multisidehole catheter can be placed over the existing
guidewire, and an injection via aTuohy–Borst adapter can
be performed around the guidewire. Finally, a second
catheter can be placed from the other groin for the fol-
low-up angiogram. Arterial pressure across the lesion before and after the procedure may be helpful in assessing
the degree of improvement in the vessel after balloon
angioplasty. Resistant osteal lesions or obstructing dissections can be treated with a renal artery stent, which should
be placed while in the oblique orientation previously determined to demonstrate the renal orifice best. An 8 Fr
guiding catheter or a long 7 Fr sheath is placed across the
lesion. Typically, a short balloon-expandable stent (i.e.,
P154) can be advanced into position across the lesion.
The guiding catheter or sheath is retracted, and contrast
is injected through the guiding catheter or sheath to
document the location of the stent in reference to the
lesion. The stent position then can be adjusted and deployed with precision. The postdeployment position can
again be determined by injection through the guiding
catheter or sheath. Renal spasm can be treated with additional doses of intraarterial nitroglycerin. Thrombosis of
the renal artery can be treated with a thrombolytic agent.
Distal embolization also can be treated with a thrombolytic infusion or suction thromboembolectomy using a
guiding catheter or the Possis Angiojet. The most feared
complication is that of renal arterial rupture. The patient
may experience continued pain after balloon deflation.
82 B. M. Hoppenfeld and J. Cynamon
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A–E
F–J
FIGURE 7-12. A 32-year-old man with hypertension, poorly controlled on three medications, and renal failure presented with a
failing renal transplant. The transplant artery continued to demonstrate increased flow velocities on duplex ultrasound despite
two attempts at surgical correction. (A) Renal transplant artery is identified off the right external iliac artery (from a right common
femoral artery retrograde approach). (B) Selective renal transplant arteriogram demonstrates the looping course of the transplant
artery. Multiple lesions were noted, including a distal kink in the artery. (C) Post 4 mm ⫻ 2 cm balloon angioplasty arteriogram
demonstrates resolution of the dysplastic appearing lesions but no change in the distal kink. (D) A prolonged 5 mm ⫻ 2cm
balloon inflation was performed at the distal lesion. (E) Elevated intrarenal pressures and a residual angiographic lesion confirm
a persistent stenosis. (F)A7⫻ 40 mm Smart Stent (Cordis, Johnson & Johnson Corp.) was deployed across the lesion as well
as across the adequately dilated portion of the renal artery. (G) The Smart Stent demonstrates a kink at the same region. (H)
The Stent then is expanded with the 5 mm ⫻ 2 cm balloon. (I) Good angiographic result is obtained with no pressure gradient.
(J) Unsubtracted view of the post stent arteriogram demonstrating the appearance of the Smart Stent in this tortuous renal artery.
The blood pressure management improved with the patient using only one medication. Renal function also improved with the
blood creatinine level decreasing to 1.6 mg/dL.
In addition, extravasation of contrast during the postprocedure angiogram may be seen. If a renal artery rupture
is noted, the balloon should be reinflated immediately
across the renal artery rupture to tamponade the vessel.
The patient then is brought to the operating room for
repair of the vessel; alternatively, a covered stent can be
placed to exclude the rupture from circulation. The results of renal angioplasty are discussed later in this book.
If an obstructing flap occurs during renal angioplasty
or if elastic recoil prevents the renal artery from being
adequately dilated, a stent can be placed in the renal
artery to salvage an otherwise failed angioplasty (Fig.
7-12). Renal stents probably should not be placed in
vessels smaller than 6 mm because the long-term results
are poor. Care must be taken to position the stent appropriately in the renal artery. In an osteal lesion, the stent
should protrude into the aorta by a millimeter or two to
ensure that the osteal lesion is totally covered.
Angioplasty or stenting of the subclavian artery, the
carotid arteries, and the mesenteric vessels all have been
performed (Fig. 7-13). The techniques are similar to
angioplasty and stenting elsewhere as described here;
however, a thorough understanding of the anatomy and
physiology of the region being treated is necessary to
treat appropriately and successfully the symptomatic lesions.
■ Techniques for Thrombolysis
Acute and subacute occlusions of native arteries and bypass grafts can be treated using a fibrinolytic agent. The
indications and contraindications and results are discussed in subsequent chapters.
Urokinase was the agent of choice for most interventional radiologists because of its known dosing efficacy
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83
D–F
FIGURE 7-13. A 79-year-old woman with congestive heart failure and status post myocardial infarction, a poor operative risk for
conventional surgery, presents with a history of right hemispheric transient ischemic attacks. (A) Arteriogram performed from the
right common femoral artery demonstrates an ulcerated stenosis of the right internal carotid artery. (B) A guiding catheter is
advanced into the right common carotid artery and an 0.018-inch platinum-tipped guidewire is used to cross the lesion. (C) The
lesion is predilated with a 4-mm balloon, and an 8 ⫻ 40 mm Wallstent (Boston Scientific Corp.) is advanced across the lesion.
(D) The Wallstent is deployed across the lesion. (E) The Wallstent is postdilated with a 6 mm ⫻ 4 cm balloon. (F) Poststent
angiogram demonstrates no significant residual stenosis of the internal carotid artery with a small residual ulcer present.
(80 to 120,000 U/hour) and acceptable complication
rate. All the lytic agents work by activating the body’s
endogenous lytic enzyme, plasmin. Plasmin will degrade
fibrin plugs. If a systemic lytic state is reached, any site of
vascular injury may bleed. Therefore, rather than use systemic, intravenous lysis, interventional radiologists have
advanced the concept of direct lytic infusion into the
thrombus. Because urokinase is not currently available,
other lytic agents are being used and evaluated: Alteplase
(r-tPA, recombinant tissue plasminogen activator, Genentech, Carmel, NY, U.S.A.) at 0.5 to 1 mg/hour and Retavase (r-Reteplase, recombinant plasminogen activator,
Centocor, Inc., Malvern, PA, U.S.A.) at 0.5 to 1 unit/hour
are being used with good results.
31–37
The diagnostic angiogram usually is performed via the
asymptomatic extremity. After the occlusion is identified
and the decision to treat with lysis is made, it can be
performed via the original puncture or via a direct puncture of the CFA of the affected extremity. Iliac occlusions
invariably are treated around the bifurcation, whereas
SFA or infrapopliteal artery occlusion can be treated with
either approach. The advantage of using the original
puncture is that an additional puncture on the side requiring lysis is not performed, thereby reducing the incidence of bleeding from a puncture site. The disadvantage
is that any follow-up therapy such as angioplasty, aspiration, or stenting in the popliteal or tibial vessels may be
more difficult.
The next step is to advance a catheter into the occluded native artery or bypass graft (Figs. 7-14 and 7-15).
It is best to advance a catheter with multiple sideholes
where the end hole either is occluded by a valve, as in
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