title: Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: a comparative study in the first 253 cases.
abstract: OBJECTIVE
  The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure.
  
  
  METHODS
  From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge.
  
  
  RESULTS
  There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively.
  
  
  CONCLUSIONS
  Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.
authors.affiliation: 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: Anil P
authors.initials: AP
authors.lastname: Hingorani
authors.forename: Richard W
authors.initials: RW
authors.lastname: Schutzer
authors.forename: Manikyam
authors.initials: M
authors.lastname: Mutyala
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D000800:Angioplasty, Balloon / Q000009:adverse effects; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D003251:Constriction, Pathologic; D004210:Dissection; D005069:Evaluation Studies as Topic; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging* / Q000601:surgery; D005471:Fluoroscopy; D005500:Follow-Up Studies; D006801:Humans; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000000981:diagnostic imaging* / Q000601:surgery; D015641:Radiography, Interventional; D012720:Severity of Illness Index; D015607:Stents; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D017539:Tunica Intima / Q000601:surgery; D018615:Ultrasonography, Doppler, Color; D018084:Ultrasonography, Interventional; D014654:Vascular Patency