title: Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: an alternative in patients with renal insufficiency.
abstract: BACKGROUND
  The technique of balloon angioplasty of infrainguinal arteries requires standard arteriography and fluoroscopic guidance. We attempted to perform this procedure under duplex guidance to avoid the use of nephrotoxic contrast material and radiation exposure in patients with renal insufficiency.
  
  
  METHODS
  Over 16 months, 28 patients (17 men) with serum creatinine levels of 1.5 mg/dL or more underwent 37 lower extremity duplex-guided balloon angioplasties at our institution. Ages ranged from 58 to 92 years (mean +/- SD, 74 +/- 9 years). Disabling claudication was the indication in 24 cases (65%), and critical ischemia, in 13 cases. Preoperative duplex arterial mapping showed severe superficial femoral artery and/or popliteal artery stenoses in all cases. No arterial occlusions were treated in this series. Seven procedures (19%) were performed for restenosis. The ipsilateral common femoral artery was cannulated in 32 cases (86%), and the contralateral common femoral artery, in 5 cases (14%), under direct duplex visualization. Contralateral common iliac artery cannulations were performed with the help of fluoroscopy. By using sonographic visualization, a guidewire was directed into the origin of the superficial femoral artery, across the diseased segment, and into the popliteal artery. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Plaque dissections and recoils causing stenosis of 30% or more, a peak systolic velocity ratio of 2 or more, or both were stented under duplex guidance. Arterial duplex examinations and ankle/brachial indexes were obtained before hospital discharge, within 1 month after the procedure, and every 3 months thereafter.
  
  
  RESULTS
  Thirty-day survival was 100%. Local complications included one open exploration for expanding hematoma. Technical success was achieved in all cases. Placement of intraluminal stents was deemed appropriate in 23 (62%) of 37 cases. The 1-month patency and limb salvage rates were 100%. Preprocedure and postprocedure ankle/brachial indexes ranged from 0.3 to 0.9 (mean +/- SD, 0.64 +/- 0.16) and 0.64 to 1.2 (mean +/- SD, 0.92 +/- 0.15), respectively (P < .0001).
  
  
  CONCLUSIONS
  Duplex-guided balloon angioplasty seems to be a safe and effective technique that allows renal patients to experience continued limb salvage and relief from claudication without the risk of developing dye-induced acute renal failure. Other advantages include direct visualization of the puncture site, accurate selection of the proper size of balloon and stent, confirmation of the adequacy of the technique by hemodynamic and imaging parameters, and avoidance of radiation. Although this technique holds considerable potential, longer follow-up will help to fully evaluate its broader applicability.
authors.affiliation: Vascular Surgery Division, Maimonides Medical Center, Brooklyn, NY 11219, USA. aober@maimonidesmed.org
authors.forename: Enrico
authors.initials: E
authors.lastname: Ascher
authors.forename: Natalie A
authors.initials: NA
authors.lastname: Marks
authors.forename: Richard W
authors.initials: RW
authors.lastname: Schutzer
authors.forename: Anil P
authors.initials: AP
authors.lastname: Hingorani
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D001783:Blood Flow Velocity; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation; D003404:Creatinine / Q000097:blood; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D051437:Renal Insufficiency / Q000097:blood / Q000150:complications*; D015607:Stents; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods*
chemical_list: D003404:Creatinine