43 Rajesh Subramanian Stephen R. Ramee Endovascular therapy has come a long way since Charles Dotter frst described angioplasty with stiff Teflon catheters to treat atherosclerotic obstructive lesions in the vasculature! ‘Whileseveral ndividualshave contributed totheuseand suc- cess of endovascular therapies, the efforts of Andreas Grunizig and John Simpson, with their concepts of expand- able polyvinyl chloride balloon catheters and steerable guidewires, respectively, revolutionized the technique of balloon angioplasty inthe 1980s and were responsible for the rapid technological advances in recent years While assess- ing theroleand impactofendovascular therapiesitwouldbea fallacy to consider balloon angioplasty and stenting separate- ly. What follows below is a description ofthe indications and technique ofballoon angioplasty, which ssimilarforstenting, Further, while the results of balloon angioplasty ae discussed below, oneshould bear in mind that balloon angioplasty with- outstenting isofhistorial interest General principles Mechanism of balloon angioplasty Balloon angioplasty was initially thought to increase the arterial lumen size by compressing the atherosclerotic plaque against the arterial wall Plaque compression is no longer thought fo play a major role. Laminal expansion is now thought to result from fracturing or breaking of the athero- sclerotic plaque, along with the creation of intimal flaps and dissection ofthe arterial media following balloon inflation? Further, at sites of eccentric plaques, balloon inflation results instretching of thenormal vessel segment resultinginluminal expansion. The vessel, almost immediately, responds to this injury caused by balloon inflation by a process of remodeling? This vessel remodeling process, including elastic recoil and neointimal hyperplasia, isresponsible for restenosis following successful luminal expansion with balloon angioplasty Balloon angioplasty and transluminal recanalization devices Indications ‘Theindication for peripheral vascularinterventionisthepres- ence of symptomssecondary to stenosis or occlusion in thear- terial or venous system. The interventionist must insure that the risk-to-benefit ratio favors intervention. Evaluation of the patient forangioplasty includes a careful history, physical ex- amination, and review of noninvasive testing. Most sympto- ‘matic lesions canbe diagnosed withoutangiography. The role of angiography is to confirm clinical suspicion and results of noninvasive testing, determine the number, location, and morphology oflesions, and toserveasa roadmap for revaseu- larization. The goals of treatment are to relieve symptoms, preserve organ function, and/or to prolong life, Selection of patients for revascularization must take into account the severity of symptoms, the angiographic findings, and the risk-to-henefit ratio for revascularization, Furthermore, one should consider the alternative therapies available, including ‘medical and surgical options. When doing so, the morbidity and durability ofthe treatment options should be carefully assessed? Procedural success Procedural successes in carefully selected patients undergo- ingballoon angioplasty inany vascularbed are quite high. For stenoses and occlusions less than 3em long, procedural suc- cess withouta major complicationis9%. Inlongstenosesand ‘occlusions more than 3em in length, the success rate is 80%. In general short, discrete, concentric, nonostial, stenotic le- sions without significant calcium are best suited for balloon angioplasty! The presence of ostial involvement,an eccentric plaque, or the presence of significant calcium in the lesion adversely affects the technical success rate for percutaneous transluminal balloon angioplasty (PTA).!? Additionally, the pathology ofthe lesion influences outcome, with fibromuscu- lar dysplastic lesions being associated with improved out- comes compared with atherosclerotic lesions, Theacute and long-term results of balloon angioplasty dif-Parr v Endovascular interventions for vascular disease ‘able 43.1 sheaths and guising catheters commeniy used inperipheralintenention carota Envoy Guide (6F), Multipurpose Guide (6-8F),Shutle Sheath (6-8 Ewoy Guide (6F), Multipurpose Guide (6-8F1), JR Guide 6-8F1) Vertebral Subelavianinnaminate Renalimesenter Aortallac Femocaipopiteal Infrepopteal access 5-8F) fer in the different vessels and different lesion morphology. Long-term outcome depends on clinical and anatomical fac- tors, Forexample, restenosis rates are lower in claudicants vs, in limb salvage, in aortiliac disease vs. femoropopliteal or fibioperoneal disease, and with a good distal ranoffvs.a poor distal runoff? Role of stenting Stenting has broadened the indications for intervention and dramatically improved the acute and long-term success of endovascular intervention. This chapter willbe restricted toa discussion of balloon angioplasty indication and techniques since stenting is the subject of the subsequent chapter. The reader should keep in mind, however, that any balloon angio- plasty result that is suboptimal (230% residual stenosis or 25-10mm gradient postangioplasty) should be stented to pre- serve the acute successand organ viability and avoid the need for emergency bypass surgery. For a complete discussion of stenting indicationsand techniquessee Chapter 44 Technique Al patients are pretreated with oral antiplatelet therapy, in- cludingaspirin (325mg qd.)and/or clopidogrel 300-mgload followed by75mgqu.)24-48hbefore the procedure. Irespec- tive of location balloon angioplasty is performed inaseriesof steps. Vascular access The firstand mostimportantstep isobtaining vascular access The proper choice of vascular access and technical success of placing a percutaneous sheath is the key t0 success for peripheral intervention, Most target arterial lesions may be approached from more than one vascular access site (See ‘Tables3.4). Familiarity of he operator, proximity orease of ap- proachability tothe target vessel or echnical concernsregand- ing the usual or preferred site dictate the choice ofthe vascular Envoy Guide (6F), Multipurpose Guide (6-8 Fr, IMAGuide 6-8F1) IMA Guide (6-8, Hockey Sick Guide( 6-861) Regular Sheath (6-86), ite tp 35cmlong sheath (6-81) Cossove Sheath (6-3), Aton Sheath antegrade femeral access: 5-8) Crossover Sheath (6-88), Multiurpose Guide (Fi), Arow Sheath (Retrograde femoral acess6-8F¥); Regular Sheath antegrade femoral access site, The common femoral artery is often the preferred location of vascular access, Thisis the most common vascular access site for diagnostic angiography and thus operator fa- riliarity plays a critical roe in its selection for intervention, “Most vascular beds can be approached via a femoral route ‘with infrainguinal intervention viaa retrograde contralateral or an ipsilateral antegrade approach and supraingainal, aor- ti, and that of most aortic branches via a retrograde common femoral approach, However, other vascular access sites may be preferred in specific situations. A brachial or radial artery approach may be preferred when there isthe presence of ex- cessive tortuosity or occlusive disease in the aortiliac seg- ‘ment. When planning renal or mesenteric angioplasty a target ‘vessel witha cephalad takeoffmay be better approached from thearm, Angioplasty ofthebrachiocephalicor ertebralartery ‘may also be better approached from the ipsilateral radial or brachial artery in cases of excessive tortuosity of the subcla- vian or brachiocephalic artery. There may be other situations (ome of these are discussed below) where a particular ap- proach may be better suited fora particular target lesion and hence this key step of obtaining vascular access must be planned for carefully. While consideringissues regarding vas- calla access, itis important to consider the distance between theaccesssiteand the target vesselascistance may limitdeliv- cerability of equipment Using the modified Seldinger technique, a needle and wire are inserted percutancously and then a sheath is inserted ina coaxial manner atraumatically. Heparin (3000-5000 U) is administered by ether the intravenous or intraarterial route Baseline angiography After obtaining vascular access one then proceeds with obiaining baseline angiography. An appropriate diagnostic catheter is used to canmulate the target vessel and imaging is performed to locate and visualize the target lesion. Ifdiagnos- tic images were performed previously then one may choose theangiographic views that best uncovered the stenosisanda “working view” may then be selected. On occasion multiple angulations and different angiographic views may be needed‘chapter 43 Balloonangioplasty and transluminal recanalization devices touncover the lesion. Itisimportant to visualize the entire tar- get vessel including the inflow and outflow. While imaging ‘one must continue cine-imaging until the venous flow is reached ioestablish the presence orabsence of collateral circu lation, tis equally important to image other vessels that are known sources of collateral circulation t0 the culprit vessel (eg, imaging all the arch vessels when there is occlusive dis- case involving one of the arch vessels or imaging the internal ‘mammary artery when there is aoroiliac occlusion and there is a paucity of collaterals from the subdiaphragmatic aortic branches), ‘With regard tothe choice of radiographic contrast we prefer the use oflow osmolaragents,as these are associated with less adverse effects and improved patient comfort. Both ionic (Hexabrix) and nonionic (Omnipaque) agents may be used While injecting radiographic contrast one must take into ac- count the vessel diameter. Radiographic contrast injection ofa sufficient volumeand rateshould be performed towel visu ize the vessel. Insufficient contrast volume or rate of injection ‘may lead to inadequate visualization of the lesion ‘There have been advances in imaging technology that can be very advantageous for the practicing vascular specialist While performing imaging of the peripheral vasculature, cineangiography is preferred over conventional cut film as this allows an appreciation of blood flow in addition to Iumenography. Digital imaging has significantly improved image quality. Further utilization of the technique of digital subiraction angiography (DSA) isexiremely useful compared ‘with standard digital angiography. DSA enables one to image the vasculature without interference of soft tissue or bony artifacts. This technique also enables one to utilize less radiographic contrast. DSA is performed by initially makinga ‘mask ofthe area of interest followed by imaging with radio- graphic contrast, the mask of the nonvascular structures is removed leaving the image of the contrast-filled vasculature Another technique that is invaluable to the interventionist is roadmapping, During the technique of roadmapping a nega- tive image ofthe vascular area of interest is superimposed on the fluoroscopic image. Thisallows one to “visualize” the ves- sel asone advancing the guidewire across the area ofsteno- sis or occlusion. This technique increases success in crossing the lesion as well as decreasing procedural time and thus the radiation exposure. Choice of equipment ‘Once thebaseline angiography i performed, itisimportantto evaluate the target vessel diameter. This may be performed with the use of intravascular ultrasound or by comparing the target vessel diameter with an object of known dimensions, Depending on the location ofthe target lesion an appropriate sheath is selected (6-8 Fr, standard vs. long vs. crossover sheath). Thesize ofthesheath isoften dictatedby thesizeofthe balloon tobe used orstent tobe delivered (Table 43.1, Table 43.2 Guidewiresusedinpatpheraintewentons Caroid 18a 200m —Roadrunner* 0.14inx200em—Sportt ‘—Belancedmedium weight? ‘—Balancecheavyweightt Platnum Plust Intacranial 0. 14inx200em—Choice PT Whisper? Vertebral 0. 18nx200cm—Roadrunner wire (0.14inx200 em—Sport —Belancedmecim weight, —Balancedhneavymeight —Fratinum Plus Subelavan —0.18inx300em—Rosdrunner (0.35inx200cn—Amplatzerchange* Penal 0.35inx190.an—Whaleys ‘—Spartacoet Balanced Midaleweght Benson Mesenteric 018inx190em—Steslcvet (0.35inx190m—Whaley 0.14inx190cm—Spantacoret Aotoiiac —-035inx1800n—Wholey —Amplate aide —Bertsont 0.14inx190em—Sport —Fatinum Plus —Spartacore 0.18inx190em—Roadeunner —stealeore SFAVpoplteal 035inx190em—Wholey —Amplatzexta sit =clde Benson Rosen? 0.14inx190cm—Sport —Fratinum Plus —Spartcore 0.18inx190em—Roadeunner —stealeare Infaporlteal 0.14inx t90em—spert —Fatinum Plus —Spartacore 0.18inx190em—Readrunner —Stealeae Manufacher: *Cook.*Guidant, Temecula, CA, USA, #BostonScentife, Natick, MA, USA, §Malinckrodt,StLous, MO, USA, ‘The next step is the choice of guidewire. Peripheral uidewires come in a range of sizes from (014 in to 0.038 in diameter (Table 43.2), Guidewires may be either hydrophilic (eg. Glide-wire) ornonhydrophilic e.g. Wholey or Amplatz). Hydrophilic guidewires are preferred wien crossing occli- sions or traversing complex lesions. Coronary guidewires