TH ERAPEUTI C CH ALLEN GE
I n fr a poplit e a l a n giopla st y : t h e m or e a r t e r ie s a r e t r e a t e d t h e be t t e r ?
Rica r do de Alva r e n ga Yosh idaI; Ca r los Edu a r do Cu n h a da Silv aI I; M a r con e Lim a Sobr e ir aI I I; W in st on Bon e t t i Yosh idaI V
IVascular and endovascular surgeon. Graduat e st udent and collaborat or, Angiology, Vascular and
Endovascular Surgery, Faculdade de Medicina de Bot ucat u ( FMB) , Universidade Est adual Paulist a ( UNESP) , Bot ucat u, SP, Brazil.
I IVascular surgeon, Hospit al Meridional de Cariacica, Cariacica, ES, Brazil. Form er resident ,
Angiology, Vascular and Endovascular Surgery, FMB, UNESP, Bot ucat u, SP, Brazil.
I I IHired physician, Angiology, Vascular and Endovascular Surgery, FMB, UNESP, Bot ucat u, SP,
Brazil.
I VAssociat e professor, professor, Angiology, Vascular and Endovascular Surgery, FMB, UNESP,
Bot ucat u, SP, Brazil.
Correspondence
J Vasc Bras. 2008; 7( 2) : 176- 182.
I n t r odu ct ion
At herosclerosis is considered as a civilizat ion disease, which grows w it h it and increasingly affect s younger individuals.1 , 2 Wit h an apparent ly irregular worldwide dist ribut ion, it is m anifest ed in around 3- 10% of t he populat ion,2 - 4 increasing t o 15 - 20% in people aged 70 year s or older.3 , 4 Mean annual incidence of sym pt om at ic peripheral art erial occlusive disease ( PAD) , at herosclerosis, according t o a st udy by Fram ingham ,5 is 26/ 10,000 m en and 12/ 10,000 wom en, increasing wit h age.
I n it s init ial present at ion, 20- 30% of pat ient s aged 50 year s or older are asym pt om at ic, 30- 40% have at ypical leg pains, 10- 35% have t ypical int erm it t ent claudicat ion, and 1- 3% have crit ical ischem ia.3 , 4 Aft er 5 years of evolut ion, am ong pat ient s w ho init ially did not have crit ical ischem ia, 70- 80% st abilized t he claudicat ion sym pt om s, 10- 20% had t heir claudicat ion worsened, and 5-10% developed crit ical ischem ia.3 , 4 I n pat ient s who have crit ical ischem ia init ially, 45% survive wit h bot h lim bs, 30% are am put at ed, and 25% die.3 , 4
Based on m any epidem iological st udies conduct ed over t he past decades, risk fact ors for PAD influencing it s nat ural course have been est ablished, increasing it s incidence and accelerat ing it s progression.3 , 4 The m ain risk fact ors are age, gender, dyslipidem ia, sm oking habit , hypert ension, diabet es m ellit us ( DM) , obesit y, hyperhom ocyst einem ia, and genet ic or fam ily fact ors of
likelihood t o undergo am put at ion t han non- diabet ic pat ient s.3 , 4
I n diabet ic pat ient s, part icularly in t hose w ho oft en have crit ical ischem ia wit h m ult isegm ent al and predom inant ly dist al lesions ( infrapoplit eal) , successful revascularizat ion, especially using venous conduit s, reduces r isk of m aj or am put at ions.2 - 4 , 6 - 1 4 More recent ly, due t o t he developm ent of new endovascular m at erials, cat het ers, low er pr ofiles and im provem ent in surgeons' learning curve, infrapoplit eal angiography has becom e an at t ract ive alt ernat ive, since it is less invasive and has good im m ediat e out com es.3 , 4 , 6 - 8 , 1 1 - 2 2
This art icle aim s at discussing, using an illust rat ive case, t o what ext ent dist al revascularizat ion should keep on using t he endovascular t echnique.
Pa r t I - Clin ica l ca se
Pr e viou s h ist or y a n d su r gica l de scr ipt ion
The pat ient is a 68- year- old wom an, born in São Manoel ( SP, Brazil) , hypert ensive, diabet ic, cardiac, ex- alcoholic ( 4 t o 5 doses of alcohol/ day for 20 years) and sm oker ( 38 years/ pack) , wit h PAD, diabet ic m acroangiopat hy and m icroangiopat hy.
Two m ont hs ago, t he pat ient was successfully subm it t ed t o an angioplast y using self- expandable prim ary st ent of t he right proxim al superficial fem oral art ery, angioplast y using balloon- cat het er of t he fem oropoplit eal t ransit ion and t ibiofibular t runk ( TFT) lesion. She st art ed present ing poplit eal pulse, m aint aining dist al pulses absent , but wit h im port ant clinical im provem ent . Ankle- brachial indexes ( ABI ) of t he ant erior t ibial art ery ( AT) and fibular art ery, which w ere init ially 0.46, raised t o 0.57, and t he post erior t ibial art ery ( TP) index rem ained zero.
Guided by road- m ap, t he fibular art ery lesion was t ransposed wit h a 260 cm , 0.035 m m St iff hydrophilic guide wire and vert ebral cat het er wit h difficult y, since it was a calcified lesion. Aft er t ransposit ion, a select ive angiography was perform ed t o ensure t hat t he guide w ir e was in t he vessel lum en (Figure 4) . An angioplast y of t he lesion was perform ed using a 3.0 X 120- m m cat het er- balloon ( Sailor, I nvat ech, OTW, 0.035 m m , 5F) , w it h im m ediat e success shown in
Th e r a pe u t ic ch a lle n ge
- Would t he t reat m ent of AT art ery m ean any risk of losing it ?
- Would such addit ional t reat m ent , if successful, be cost- effect ive?
Pa r t I I - W h a t w a s pe r for m e d?
Su r gica l de scr ipt ion
The choice was for approaching t he AT art ery and t rying t o recanalize it . A select ive cat het erizat ion of t he AT art ery arch was perform ed using t he guide wire and cat het er of t he previous procedure. The guide wire was insert ed dist ally, w it h a cert ain resist ance, unt il reaching t he dorsal art ery of foot , which was pat ent Figure 6) . The vert ebral cat het er was replaced by t he cat het er- balloon used in t he previous procedure. Cont rol art eriography using t he cat het er- balloon showed t hat t he
Final cont rol show ed wall dissect ion at t he origin of fibular and AT art eries (Figure 7) , choosing for st ent ing bot h art eries. The guide wire had t o be replaced by a floppy- t ipped 300 cm , 0.014 wire. I nit ially, t he fibular art ery was st ent ed wit h a 3.0 x 56- m m st ent ( self- expandable Crom is,
By t he end of t he procedure, t here was pulse in t he AT art ery and in t he dor sal art ery of foot , and t he ABI of t he fibular art ery was 1.0. The 11- cm 6F sheat h was rem oved 2 hours aft er t he
The pat ient was m aint ained wit h plat elet ant iaggregat ing drugs, acet ylsalicylic acid ( 200 m g/ day) and clopidogrel ( 75 m g/ day) , in addit ion t o her usual m edicat ions, progressing w it h significant reduct ion of pain, and not requiring use of analgesic drugs, wit h m aint enance of pulse in AT and dorsal art ery of foot unt il her last visit 1 m ont h aft er t he procedure.
D iscu ssion
The sim plicit y and t echnical elegance of int roducing int raart erial cat het ers caused a revolut ion in t he diagnosis and t reat m ent of peripheral cardiovascular disease2 3 , 2 4 t hat , in addit ion t o t he
cont ribut ions by Dot t er & Judkins,2 5 Am plat z2 6 and Grunt zig et al.,2 7, accelerat ed t he developm ent of endovascular int ervent ions. These were t he first m inim ally invasive t herapies current ly applied t o ot her t ypes of at herosclerot ic disease, such as PAD. However, not all peripheral vascular t errit ories have w ell- defined consensus t reat m ent .3 , 4 , 1 3
Experience wit h infrapoplit eal angioplast y is lim it ed. According t o TASC I I ,3 , 4 t here is growing evidence support ing t his t reat m ent for lim b salvat ion in pat ient s w ho have st enot ic or occluded infrapoplit eal art eries, but only when t here is presence of dist al run- off in t he foot in pat ient s at high surgical r isk and t o save previous dist al graft s. I ndicat ion t o t r eat int erm it t ent claudicat ion is st ill cont roversial,3 , 4 as well as use of st ent s in t his t errit ory.3 , 4 , 1 8 , 1 9
There is 90% success rat e in im m ediat e out com es of t he endovascular t reat m ent of dist al lesions, according t o TASC I I .3 , 4 A m et a- analysis1 3 including 1,282 t reat ed lim bs show ed 93% im m ediat e success of lim b salvat ion, and 74% aft er 1 year. I n a previous case series, lim b salvat ion rat es were bet ween 76 and 94% .6 - 8 , 1 0 - 1 2 , 1 4 , 1 6 - 1 8 , 2 0 - 2 2
However, endovascular t reat m ent of infrapoplit eal lesions has a high pot ent ial of com plicat ions, am ong which are art erial spasm , art erial perforat ion using guide wire, usually self- lim it ed, int im al dissect ion wit h no art ery occlusion, int im al dissect ion wit h art ery occlusion, dist al em bolism and balloon- relat ed art ery rupt ure, and t hrom bosis of t reat ed vessel.2 8 There m ay be sit uat ions in which, in t he at t em pt of recanalizing an art ery, anot her adj acent art ery is occluded, especially in bifurcat ions in which t he plaque is not only lim it ed t o t he art ery being t reat ed.2 8
However, som e sit uat ions rem ain uncert ain. I t has been w ell defined by TASC I I3 , 4 t hat in pat ient s who have crit ical ischem ia wit h proxim al and dist al lesions, bot h of t hem should be t reat ed
concom it ant ly t o cause healing, im prove procedure pat ency and reduce risk of lim b loss. On t he ot her hand, t her e is no definit ion as t o how m any and which art eries should be t reat ed, especially in case of occlusive art eries. I n addit ion, in diabet ic pat ient s, in whom t he dist al lesions are prevalent ,3 , 4 , 7 it is not known whet her t he independent t reat m ent of an art ery, t he fibular art ery, which is t he m ost preserved, is enough t o heal wounds and reduce am put at ion r at e, or whet her t here is need of revascularizat ion of at least one t ibial art ery t o obt ain bet t er result s.7 , 8
Only one case ser ies st udy has discussed t hese issues. Faglia et al.7 observed t hat som e pat ient s who had init ial t echnical success present ed worsening of lesions and did not heal as expect ed. I n t hese pat ient s, angiographic cont rol show ed t hat t he t reat ed art eries rem ained pat ient , wit h no hem odynam ically significant st enoses. Thus, analysis of t he case series showed t hat :
- I n angioplast y perform ed only in t he proxim al segm ent , in pat ient s wit h concom it ant dist al im pairm ent , t he probabilit y of m aj or am put at ion is st ill high.7
- Recanalizat ion of at least one t ibial art ery im plied reduct ion in m aj or am put at ion rat es.7
- Measurem ent of part ial oxygen t ension ( pO2) before angioplast y had no st at ist ical difference in pat ient s w ho needed or not am put at ion, and was not a predict or for it . On t he ot her hand, success of angioplast y associat ed wit h increase in pO2 above t he init ial basal value was relat ed t o lim b salvat ion. Therefore, increase in pO2 above basal values aft er angioplast y m ay be a predict or of lim b salvat ion.7
Alt hough t his st udy7 is not m ult i- cent ered or random ized, m aj or issues have been raised, which will serve as guide for furt her st udies. Based on t his case report , it m ight be inferred t hat t he
endovascular t reat m ent of infrapoplit eal lesions is an elegant form of t reat ing t hese lesions, wit h good out com es in lim b salvat ion. Decision as t o which art eries should be t reat ed in dist al lesions should be t he obj ect of m ore st udies for t he est ablishm ent of prot ocols, aim ing at bet t er result s.
Re fe r e n ce s
1. Yoshida R, Yoshida W, Maffei F, et al. Com parat ive st udy of evaluat ion and out com e of pat ient s wit h int erm it t ent claudicat ing, w it h or wit hout lim it at ion for exercises, followed in specific out-pat ient set t ing. J Vasc Bras. 2008; " I n Pr ess" .
2. Last oria S, Maffei F. At erosclerose oblit erant e periférica: epidem iologia, fisiopat ologia, quadro clínico e diagnóst ico. I n: Maffei F, edit or. Doenças vasculares periféricas. 3ª ed. São Paulo: Medsi; 2002. v. 2. p. 1007- 24.
3. Norgren L, Hiat t WR, Dorm andy JA, et al. I nt er- Societ y Consensus for t he Managem ent of Peripheral Art erial Disease ( TASC I I ). J Vasc Surg. 2007; 45 Suppl S: S5- 67.
4. Norgren L. [ New int ernat ional consensus docum ent on peripheral art erial disease. TASC I I for im proved care]. Lakart idningen. 2007; 104: 1474- 5.
5. Kannel WB, Skinner JJ Jr., Schwart z MJ, Shurt leff D. I nt erm it t ent claudicat ion. I ncidence in t he Fram ingham st udy. Circulat ion. 1970; 41: 875- 83.
6. Faglia E, Clerici G, Cam init i M, Quarant iello A, Curci V, Morabit o A. Predict ive values of t ranscut aneous oxygen t ension for above- t he- ankle am put at ion in diabet ic pat ient s wit h crit ical lim b ischem ia. Eur J Vasc Endovasc Surg. 2007; 33: 731- 6.
7. Faglia E, Clerici G, Clerissi J, et al. When is a t echnically successful peripheral angioplast y
effect ive in prevent ing above- t he- ankle am put at ion in diabet ic pat ient s wit h crit ical lim b ischaem ia? Diabet Med. 2007; 24: 823- 9.
8. Faglia E, Mant ero M, Cam init i M, et al. Ext ensive use of peripheral angioplast y, part icularly infrapoplit eal, in t he t reat m ent of ischaem ic diabet ic foot ulcers: clinical result s of a m ult icent ric st udy of 221 consecut ive diabet ic subj ect s. J I nt ern Med. 2002; 252: 225- 32.
9. Albers M, Rom it i M, Brochado- Net o FC, De Luccia N, Pereira CA. Met a- analysis of poplit eal- t o-dist al vein bypass graft s for crit ical ischem ia. J Vasc Surg. 2006; 43: 498- 503.
11. Diffin DC, Kandarpa K. Percut aneous recanalizat ion of peripheral art erial occlusions. World J Surg. 2001; 25: 312- 7; discussion 317- 8.
12. Johnst on K. Endovascular surgery in t he m anagem ent of chronic lower ext rem it y ischem ia. I n: Rut herford R, edit or. Vascular surgery. 6t h ed. Denver: Elsevier Sauders; 2006. v. 2. p. 1192- 221.
13. Kandarpa K, Becker GJ, Ferguson RD, Connors JJ 3rd, Woj ak JC, Landow WJ. Transcat het er int ervent ions for t he t reat m ent of peripheral at herosclerot ic lesions: part I I. J Vasc I nt erv Radiol. 2001; 12: 807- 12.
14. Sigala F, Menenakos C, Sigalas P, et al. Translum inal angioplast y of isolat ed crural art erial lesions in diabet ics wit h crit ical lim b ischem ia. Vasa. 2005; 34: 186- 91.
15. Kandarpa K, Becker GJ, Hunink MG, et al. Transcat het er int ervent ions for t he t reat m ent of peripheral at herosclerot ic lesions: part I. J Vasc I nt erv Radiol. 2001; 12: 683- 95.
16. Golzar JA, Belur A, Cart er LI , Choksi N, Safian RD, O'Neill WW. Cont em porary percut aneous t reat m ent of infrapoplit eal art erial disease: a pract ical approach. J I nt erv Cardiol. 2007; 20: 222- 30.
17. Jahnke T, Link J, Muller- Hulsbeck S, Grim m J, Heller M, Brossm an J. Treat m ent of infrapoplit eal occlusive disease by high- speed rot at ional at herect om y: init ial and m id- t erm result s. J Vasc I nt erv Radiol. 2001; 12: 221- 6.
18. Peet ers P, Bosiers M, Verbist J, Deloose K, Heublein B. Prelim inary result s aft er applicat ion of absorbable m et al st ent s in pat ient s wit h crit ical lim b ischem ia. J Endovasc Ther. 2005; 12: 1- 5.
19. Tset is D, Belli AM. The role of infrapoplit eal angioplast y. Br J Radiol. 2004; 77: 1007- 15.
20. Ansel GM, Sam ple NS, Bot t i I C Jr., et al. Cut t ing balloon angioplast y of t he poplit eal and infrapoplit eal vessels for sym pt om at ic lim b ischem ia. Cat het er Cardiovasc I nt erv. 2004; 61: 1- 4.
21. At ar E, Siegel Y, Avraham i R, Bart al G, Bachar GN, Belenky A. Balloon angioplast y of poplit eal and crural art eries in elderly wit h crit ical chronic lim b ischem ia. Eur J Radiol. 2005; 53: 287- 92.
22. Haider SN, Kavanagh EG, Forlee M, et al. Two- year out com e wit h preferent ial use of infrainguinal angioplast y for crit ical ischem ia. J Vasc Surg. 2006; 43: 504- 12.
23. Seldinger SI . Cat het er replacem ent of t he needle in percut aneous art eriography. Act a Radiol. 1953; 39: 368- 76.
24. Francisco Jr. F, Jacques N. Angioplast ia t ranslum inal percut ânea. I n: Maffei F, edit or. Doenças vasculares periféricas. 3ª ed. São Paulo: Medsi; 2002. v. 1. p. 843- 64.
25. Dot t er CT, Judkins MP. Translum inal t reat m ent of art eriosclerot ic obst ruct ion: descript ion of a new t echnique and a prelim inary report of it s applicat ion. Circulat ion. 1964; 30: 654- 70.
26. Am plat z K. A cardiovascular inj ect or. Radiology. 1960; 74: 79- 80.
27. Grunt zig AR, Senning A, Siegent haler WE. Nonoperat ive dilat at ion of coronary- art ery st enosis: percut aneous t ranslum inal coronary angioplast y. N Engl J Med. 1979; 301: 61- 8.
Cor r e spon de n ce :
Ricardo de Alvarenga Yoshida Depto. de Cirurgia e Ortopedia
Faculdade de Medicina de Botucatu, UNESP CEP 18618-970 – Botucatu, SP, Brazil Tel.: (14) 3811.6269
Email: ricardoyoshida@gmail.com
No conflicts of interest declared concerning the publication of this article.