Assisted
primary patency through transluminal angioplasty in revascularization
surgery
of critically ischemic lower limbs
(Portuguese
PDF version) Fabio
H. Rossi1, Nilo M. Izukawa2, Lannes A.V. Oliveira1,
Domingos G. Silva1, Simone N.S.M. Barreto3,
Mohamed Saleh3, Hudson C.R. Carvalho3, Adriana
C. Petisco3 1.
Surgical Assistant, Vascular Surgery Sector, Instituto Dante Pazzanese de Cardiologia,
São Paulo, SP, Brazil.
2. Chief Surgeon, Vascular Surgery Sector,
Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil.
3.
Medical Assistant, Ultrasonography Sector, Instituto Dante Pazzanese de Cardiologia,
São Paulo, SP, Brazil. Correspondence:
Fabio H Rossi
Instituto Dante Pazzanese de Cardiologia - São Paulo
Al. Jurupis, 900/103/IV
CEP 04088-002 - São Paulo - SP
Brazil
E-mail: vascular369@hotmail.com
ABSTRACT
Objective: Surgical revision is the traditional treatment for stenotic
lesions. Transluminal angioplasty has been recently used as a less invasive alternative
to treat such lesions. This study aims at assessing the patency results achieved
after transluminal angioplasty of stenotic lesions.
Method: Nineteen
transluminal angioplasties were performed on patients with a diagnosis of stenotic
lesions along the graft site. The following variables were analyzed: post-surgical
period since the time of transluminal angioplasty; diagnostic method; characteristics
of the stenosis; method used for transluminal angioplasty; immediate success of
procedure; complications; and mid-term patency.
Results: In 19
(61%) cases, angioplasty was considered a favorable method to treat these stenotic
lesions. Mean post-surgical time was 10.26 months. Color flow duplex scanning
was responsible for the diagnosis in 68.4% of the cases. The transluminal angioplasty
sites were the following: graft body (proximal third, distal third); distal anastomosis;
proximal anastomosis; iliac artery (proximal bed); and distal bed. After 15 months,
15 (93.75%) patients had no ischemic symptoms. A primary patency rate of 78.9%
and an assisted primary patency rate of 94% were achieved, with 100% limb preservation.
Conclusion: Transluminal angioplasty is an alternative and a less
invasive method to maintain the patency and to preserve the limbs of patients
submitted to lower limb revascularization.
Key
words: grafts, lower extremity, stenosis, angioplasty.
Palavras-chave: enxertos, membro inferior, estenose, angioplastia.
J
Vasc Br 2003;2(4):303-12
Revascularization
surgery of the lower limbs presents highly satisfactory results in patients who
suffer from critical ischemia. In four years, a graft patency rate of approximately
80% can be achieved by using a venous graft. 1-3
However, there is also an incidence of stenosis in a significant number of these
grafts (30%), which provokes intervention for maintenance of the graft patency.4-8
Postoperative follow-up and identification of the failure of these grafts
through color flow duplex scanning allows for the precocious treatment of these
lesions to obtain better results for patency and limb salvage than those achieved
after lesion obstruction. 7-9
Transluminal
balloon angioplasty is a less invasive method than surgical treatment for the
treatment of these lesions. However, the results obtained are not invariably good,
and a significant number of such procedures evolve into restenosis or obstruction
and require surgical correction.5,10-12
With the objective of analyzing the efficiency and the patency results achieved
through the use of transluminal angioplasty, 19 angioplasties were prospectively
analyzed. These angioplasties were performed on patients who had experienced previous
revascularization of the lower limb with critical ischemia and who had developed
stenotic lesions that presented favorable conditions for angioplasty and that
were identifiable via color flow duplex scanning. METHOD
Between
December 1998 and October 2002, a total of 325 lower limb revascularization surgeries
were performed on patients who suffered from critical ischemia. Those patients
considered to have critical ischemia were those that presented pain at rest, an
ischemic ulcer, chronic gangrene and those who were objectively characterized
as suffering from chronic arterial obstruction.
During this period, patients
that presented clinical signs of graft failure (pain, reduced pulse rates, problems
with the healing of the wound and decreased pressure rates) and/or the presence
of stenotic lesions in the path of the graft found during postoperative ultrasonographic
routine (performed after one month, six months and then every six months after)
were submitted to angioplasty if the lesions were considered favorable for the
procedure.
Those lesions that presented a peak systolic velocity rate
(post/pre-stenosis) >3.5 and/or that presented a blood flow velocity
in the graft less than 45 cm/s were considered severe stenotic lesions.
Some anatomical characteristics of the stenotic lesion were considered favorable
for the performance of the transluminal angioplasty. The following inclusion criteria
were observed for the lesion: single, isolated, less than 2 cm, concentric, absence
of calcification and thrombus, presence of more than two arteries in proximity
of the angioplasty site. The rigid exclusion criteria were the following: presence
of extensive stenosis (> 2 cm), eccentric arteriosclerotic plate, the presence
of less than two distal arteries at the graft site, asymptomatic stenosis in patients
with a low life expectancy and a high surgical risk.
In the case of a
favorable stenotic lesion and in the absence of the exclusion criteria, patients
were directed to the surgical center and submitted to arteriography with the use
of a surgical steel device (Stenoscope-GE/OEC 9800). After the arteriographic
confirmation of the favorable lesion, patients were submitted to balloon catheter
angioplasty.
The lesions that were considered unfavorable for angioplasty
were submitted to elective surgical intervention. The surgical techniques used
were endarterectomy, arteriotomy with venous patch implant, extension of the graft
or the confection of a new graft.
To perform the transluminal angioplasty,
the following steps were taken. After the insertion of the 6F introduction sheath
and the endovenous administration of 5,000 U of heparin, a hydrophilic guide string
(0.35") was passed through the site of the stenosis under fluoroscopic control.
The catheter balloon was also introduced in this stage. The diameter of the balloon
varied between 3 and 8 mm and the pressure used was between 10 and 15 atmospheres
(ATM). The minimum time in which the balloon remained uninflated was one minute
(1-2 min). After the control arteriography, a new angioplasty with a slightly
larger balloon (1 mm larger) was performed to check for the presence of residual
stenosis.
The following variables were prospectively evaluated: diagnostic
method for the presence of the stenotic lesion, time between primary surgery and
the diagnosis of graft failure, the anatomical and hemodynamic characteristics
of stenosis, technique and site of the angioplasty, complications, time of hospital
stay, primary patency, primary assistance and the result of mid-term patency after
the transluminal angioplasty achieved from the color flow duplex scanning. This
last variable was analyzed with the survival curve for limb salvage, primary patency
and primary assistance. RESULTS
During
the evaluated period, 325 infrainguinal revascularization surgeries were performed
on the lower limb, and 99 of this total (30.5%) were supragenicular femoropopliteal;
64 (19.6%) were infragenicular femoropopliteal; and 162 (49.9%) were femoral distal,
performed on patients that suffered from critical ischemia. The reverse venous
graft was used in 240 (74%) surgeries and prostheses were used in 85 (26%).
In these surgeries, 31 (9.53%) stenotic lesions were identified that lead
to partial graft obstruction (peak systolic velocity > 3.5) and 11 cases
of complete graft obstruction were found. Of the cases where there was total obstruction,
five occurred in symptomatic patients who were submitted to surgery (three thromboembolectomies,
two grafts) and four of these cases evolved into limb loss, demonstrating the
poor prognosis of this group of patients. The asymptomatic patients received clinical
follow-up with the preservation of their limbs during the period of the study.
Observing the aforementioned rigorous inclusion and exclusion criteria
in the 31 cases of partial graft obstruction, 19 (61.3%) cases were identified
with stenotic lesions considered favorable for angioplasty. The average age for
this group of patients was 65.4 years. Thirteen patients (68.4%) were males. The
following pathological antecedents were observed: systemic arterial hypertension
in 76%, diabetes mellitus in 40%, smoking in 76%, coronary insufficiency in 67%,
acute myocardial infarction (heart attack) in 26%, dyslipidemia in 46%, and chronic
renal insufficiency in 23%. Previous revascularization had been performed in distal
arteries in 13 cases (68.4%). The average postoperative time during which the
critical lesions were identified was 10.26 months (4-18 months). In only one patient,
the diagnosis of graft failure was made after a clinical complaint. In five patients,
there was a reduction in pulse accompanied by a reduction in arm-leg blood pressure
rate in only one patient. Color flow duplex scanning was responsible for the diagnosis
of 68.4% cases, all of which were asymptomatic (Table 1).  Table
1- Demographic characteristics in patients submitted to angioplasty of lower limb
arterial grafts
 |
|
Age |
Sex |
Previous Graft |
PO Time |
Evolution | |
|
72 |
M |
supragenicularfemoropopliteal (PTFE Pr.) |
6 months | ↓pulse
| |
67 |
M |
femorodistal (RGSV) |
12 months |
asymptomatic | |
67 |
M |
femorodistal (RGSV) |
20 months |
asymptomatic | |
57 |
M |
infragenicularfemoropopliteal (PTFE Pr.) |
10 months |
pain | |
67 |
F |
femorodistal (RGSV) |
18 months |
asymptomatic | |
78 |
F |
femorodistal (ISGSV) |
10 months | ↓pulse
+ arm-leg pressure rate | |
67 |
M |
femorodistal (RGSV) |
12 months |
asymptomatic | |
63 |
M |
femorodistal (RGSV) |
4 months | ↓pulse
| |
77 |
M |
femorodistal (RGSV) |
7 months |
asymptomatic | |
54 |
F |
femorodistal (RGSV) |
18 months |
asymptomatic | |
65 |
M |
femorodistal (RGSV) |
5 months |
asymptomatic | |
38 |
M |
femorodistal (RGSV) |
11 months |
asymptomatic | |
72 |
M |
femorodistal (ISGSV) |
6 months |
asymptomatic | |
68 |
F |
supragenicularfemoropopliteal (RGSV) |
7 months |
asymptomatic | |
68 |
F |
infragenicularfemoropopliteal (RGSV) |
13 months |
asymptomatic | |
74 |
M |
femorodistal (RGSV) |
8 months | ↓pulse
| |
66 |
F |
femorodistal (RGSV) |
7 months | ↓pulse
| |
70 |
M |
infragenicularfemoropopliteal (RGSV) |
15 months |
asymptomatic | |
70 |
M |
infragenicularfemoropopliteal (RGSV) |
6 months |
asymptomatic | |
RGSV = reverse
greater saphenous vein; ISGSV = in situ greater saphenous vein; PTFE Pr.: polytetrafluoroethylene
prosthesis.
Following the criteria described above, those patients with stenotic lesions in
the path of the graft that were favorable for balloon catheter angioplasty were
directed to a surgical center and submitted to intraoperative arteriography. There
was a concordance between the arteriography and the color flow duplex scanning
in 100% of the analyzed cases.
In this way, 19 angioplasties were performed on 16 patients. In one
case, there was restenosis at the site submitted to previous angioplasty.
In two cases, the same patient developed stenosis at two different sites.
The common femoral artery was the puncture site in 12 cases and the
popliteal artery was the puncture site in one case (retrograde). In
six cases in which the stenosis site was near regions of previous dissection
scarring, puncturing of the graft segment was performed on the distal
third of the thigh under direct visualization after surgical dissection.
The following were sites for the transluminal angioplasty: the graft
body in nine cases (seven cases: proximal third; two cases: distal third);
the distal anastomosis in four cases; the proximal anastomosis in three
cases; the iliac artery (proximal bed) in one case; and the distal bed
in two cases (Figures 1, 2 and 3).
Figure
1- Iliac artery stenosis in the common right proximal iliac artery with a previous
femoropopliteal graft treated with transluminal angioplasty. 
Figure
2- Transluminal angioplasty of the proximal anastomosis of the anterior femorotibial
graft with reverse greater saphenous vein. 
Figure
3- Transluminal angioplasty showing the infragenicular femoropopliteal graft with
PTFE prosthesis. 
The arteriographic result of the angioplasty was considered good in cases in which
there was a residual stenosis under 20% and moderate when these values were between
20 and 30%.
The graft segments on which the angioplasties were performed
and the immediate results are displayed in Table 2. Table
2- The angioplasty location and immediate results in patients who suffer from
critical stenoses and were submitted the previous revascularization of the lower
limbs
|
| Location
| Pre-
Pulse | Pre-
arm-leg pressure rate | Balloon | Angioplasty | Post-Pulse
| Post-
arm-leg pressure rate | |
| Body
| absent
| - | 4
x 20 mm | good | absent
| - |
| Iliac
| absent
| - | 8
x 40 mm |
good | 2+ | - |
| Body | absent
| 0,2 | 5
x 20 mm | good | 2+ | - |
| Proximal
Aa | 2+ | - | 6
x 20 mm | good | 3+ | - |
| Distal
Aa | absent
| 0 | 4
x 20 mm | good | 3+ | - |
| Distal
bed | 2+ | - | 4
x 20 mm | good | 4+ | - |
| Body | + | 0,3 | 4
x 20 mm | good | 4+ | - |
| Body | 3+ | 0,3 | 4
x 20 mm | good | 4+ | - |
| Distal
Aa | 2+ | - | 5
x 20 mm | moderate | 4+ | - |
| Body | 3+ | 0,2 | 4
x 20 mm | good | 4+ | - |
| Body | 1+ | 0,35 | 4
x 20 mm | good | 2+ | - |
| Distal
Aa | absent
| - | 4
x 20 mm | good | absent
| - |
| Proximal
Aa | absent
| - | 4
x 20 mm | good | absent
| - |
| Body | absent
| - | 5
x 20 mm | good | absent
| - |
| Distal
bed | absent
| - | 4
x 20 mm | good | absent
| - |
| Proximal
Aa | 2+ | - | 5
x 20 mm | good | 4+ | - |
| Body | 3+ | - | 5
x 20 mm | moderate | 4+ | - |
| Distal
Aa | 2+ | 0,3 | 4
x 20 mm | good | 4+ | 0,6 |
| Body | 2+ | 0,3 | 5
x 20 mm | good | 4+ | 0,6 |
|
Of the
performed angioplasties, 17 (89.5%) were considered to have a good arteriographic
result, and in two (10.5%) cases, the result was considered moderate. All of the
patients evolved with an improvement in pulse and/or the pressure rate. Two patients
presented initially worsened pressure rates, probably due to a temporary vessel
spasm. Two patients were submitted to concomitant angioplasties.
Only
three patients (15.8%) evolved mild hematomas at the puncture site during the
perioperative period.
During the clinical follow-up, with an average
post-angioplasty period of 15 months, 15 (93.75%) patients did not develop ischemic
symptoms. During this period, one patient evolved an asymptomatic graft obstruction.
This patient had been submitted to two previous revascularization surgeries of
the lower limb due to an ischemic ulcer that had already healed by the time of
the angioplasty.
One patient who participated in the study was not located
and did not undergo the programmed color flow duplex scanning.
Four angioplasties
that were performed (21%) evolved with asymptomatic restenosis (> 50%) during
the follow-up period. Three of these patients were asymptomatic and in one case
there was pain. One patient was submitted to a new angioplasty with favorable
evolution and two patients were submitted to surgery. The fourth patient was found
to be asymptomatic and because he presented an arterial bed that was unfavorable
to surgery, he currently continues clinical follow-up (Table 3). Table
3- Complications, Post-angioplasty follow-up period time, results (clinical and
EDC) and procedure for patients who suffer from critical stenosis who were submitted
to previous revascularization of the lower limbs
|
|
Complications |
Post-angioplasty follow-up period |
Clinical condition |
Color flow duplex scanning |
Procedure | |
|
Hematoma |
40 months |
asymptomatic | <
50% |
- | |
Hematoma |
32 months |
pain | <
50% |
- | |
- |
32 months |
pain | >
50% |
ATC | |
Hematoma |
28 months |
asymptomatic | <
50% |
- | |
- |
20 months |
asymptomatic |
- |
- | |
- |
18 months |
asymptomatic | <
50% |
- | |
- |
18 months |
asymptomatic | >
50% |
surgery | |
- |
13 months |
asymptomatic |
obstruction |
- | |
- |
12 months |
asymptomatic | >
50% |
surgery | |
- |
12 months |
asymptomatic | <
50% |
- | |
- |
10 months |
asymptomatic | >
50% |
- | |
- |
10 months |
asymptomatic | <
50% |
- | |
- |
9 months |
asymptomatic | <
50% |
- | |
- |
9 months |
asymptomatic | <
50% |
- | |
- |
8 months |
asymptomatic | <
50% |
- | |
- |
7 months |
asymptomatic | <
50 % |
- | |
- |
6 months |
asymptomatic | <
50% |
- | |
- |
3 months |
asymptomatic | <
50 % |
- | |
- |
3 months |
asymptomatic | <
50% |
- | |
In this
way, with an average period of clinical follow-up and an ultrasonographic examination
performed 15 months after the transluminal angioplasty (minimum: 3 months, maximum:
40 months), primary patency rates of 78.9% were achieved, primary assistance rates
of 94% were achieved, and limb salvage rates of 100% were achieved (Figure 4). Figure
4- Patency after angioplasty of infrainguinal grafts. 
Only three
patients evolved restricted hematomas at the puncture site, and there were no
serious complications. The average period of hospital stay was 32 hours. DISCUSSION
Graft obstruction
in lower limbs is frequently preceded by asymptomatic stenotic lesions
that can occur on areas of anastomoses, on the body or on the proximal
or distal arterial bed at the graft site.1,4-6,13-15
Its hemodynamic significance is translated into a progressive reduction
in blood flow velocity along the graft path that can lead to thrombosis.8,9,12-14,16-24
In our study, during which 325 revascularization surgeries of
the lower limbs were analyzed, 42 (12.9%) patients developed stenotic
lesions that put the graft patency at risk in this sub-group, and stenotic
lesions that were considered appropriate for angioplasty were identified
in only 16 cases (38%). Ten (62.5%) patients were completely asymptomatic,
only one patient complained of pain at rest, five patients presented
a decrease in pulse rate, and one of these patients there was a reduction
in the arm-leg pressure rate This demonstrates the importance of clinical
follow-up in these patients during the postoperative stage, principally
through color flow duplex scanning. It is important to note that the
measurement of the arm-leg pressure rate was often compromised by the
presence of calcification in the distal arteries present in a diabetic
patient and that this method is proven to be flawed in the diagnosis
of graft failure. In our study, this method was rarely used in the identification
of lesions, due as much to the presence of distal artery calcification
as to the discredit of the method by those involved in the study.
Szilagyi et al. observed that approximately 1/3 of the patients followed
for five years developed stenotic lesions on the infrainguinal venous
grafts monitored by arteriography.5 More
recent studies that use less invasive methods indicate that this phenomenon
can occur in between 12% and 30% of these grafts, primarily during the
postoperative period.8,12,14,18-24
In our study, the rate was 12.9%. However, of the 325 patients
operated, clinical follow-up was considered unsatisfactory in 76 (23.4%)
cases. Therefore, it is likely that a larger number of grafts evolved
toward obstruction and that such an occurrence was not diagnosed.
Currently, we can achieve patency rates for infrainguinal grafts of
80% in five years.1,9,13
These results are obtained in patients for which stenotic lesions are
identified and precociously treated.1,8,9,12,13
The patency of the grafts treated after thrombosis is approximately
30% during this same period.9,14,25,26
These results justify the rigorous follow-up of these patients,
primarily during the first year, as this is when the highest number
of stenoses that put the graft patency at risk occur.4,8,16,17
In our study, with a postoperative average of 10.26 months, 11 (91.6%)
patients submitted to angioplasty were asymptomatic and, in 68.4%, the
color flow duplex scan was the only examination responsible for the
diagnosis of graft failure, demonstrating the importance of this method
in the follow-up of these patients, principally in the first months
after surgery. We would like to point out again that the arm-leg pressure
rate presents a low sensitivity and specificity, especially in patients
that suffer from diabetes mellitus. Bandyk et al.18
and Mills et al.19 observed the failure
of this method to identify graft stenosis in 34% and 71% of the cases
they studied, respectively.
In 1984, Bandyk et al. were the first researchers to publish a study
demonstrating the importance of the color flow duplex scanning in the
follow-up of patients who had infrainguinal grafts of the lower limbs.20
In this study, it was suggested that the presence of a peak systolic
velocity (PSV) lower than 45 cm/s measured in the narrowest zone outside
the site of the stenosis would mean a risk of graft failure. However,
the low sensitivity of this method was criticized by certain authors.9,21
The fraction between the PSV immediately after the stenosis zone
with that obtained in a segment with a normal diameter (PSV1/PSV2) can
provide more accurate data about the degree of the stenosis. This relationship,
when larger than two, corresponds to significant stenosis, supposedly
> 50%, with a sensitivity between 83% and 94% and a specificity between
91% and 100%.9,22-24 In
addition, color flow duplex scanning allows researchers to study the
entire graft path, the proximal and distal arterial bed and identify
stenotic zones in these segments. Its negative predictive power is approximately
100% when associated with the PSV measurement.21
Currently, it appears to be the gold standard method in the follow-up
of infrainguinal grafts.4,9,17,19
In our study, of the 16 cases with stenotic lesions favorable to angioplasty
according to the ultrasonographic criteria described above, all (100%)
were confirmed by the arteriography performed before the angioplasty.
This demonstrates the sensitivity of the color flow duplex scanning
not only for the diagnosis of these lesions but also for the selection
of those that are favorable for angioplasty, a very important factor
for the success of this type of treatment.
The stenotic lesions of the venous graft include neo-intimal hyperplasia,
venous fibrosis and surplus valves. McNamara et al. 15
and Lundell et al. 8 observed that,
in studies of patients with in situ venous grafts, the majority
of these lesions were located in anastomoses zones. Berkowitz et al.
observed that, in reverse grafts, the lesions were more common in the
proximal third of the grafts (54%) 16,
a result that is quite similar to that of our patients. In 56.2% of
the cases we analyzed, the stenoses were also found in the proximal
body of the graft.
Currently, the best therapeutic approach once the graft stenosis is
identified is still being debated. This treatment can be through the
confection of a new graft, the interposition of the venous segment,
the resection and termino-terminal anastomosis, surgical angioplasty
via patch and endoluminal percutaneous angioplasty. Cohen et al. demonstrated
a patency of 82% in five years when the patients were treated with surgical
angioplasty and a patency of 43% with treatment via transluminal angioplasty.
14 In the same manner, Bandyk et al.,12
Perler et al. 27 and Whittemore
et al. 11 achieved better results with
surgical correction.
However, there are certain factors that should be considered. Infrainguinal
revascularization should be preferentially performed through an autologous
venous graft, which is not always available for this group of patients.
The interposition of prosthesis between venous segments constitutes
a less favorable alternative. When stenosis involves the zones of anastomoses,
principally the distal zones, surgical treatment involves approaching
the region attacked by scarring fibrosis that is difficult to dissect.
Surgery can mean higher risks for patients who carry severe comorbidities.
These factors can make reoperations unjustifiable in asymptomatic patients
who have no imminent risk of losing a limb.
Because of this, some authors justify the initial use of the transluminal
angioplasty due to the low morbi-mortality rates it presents, in addition
to the possibility it provides of preserving the autologous venous segment,
the low period of the hospital stay and because it does not inhibit
the performance of later surgery if it becomes necessary.
Berkowitz et al., performed transluminal angioplasty on 61% of patients
that experienced infrainguinal graft failure. The researchers observed
restenosis in 29% of the patients after the first angioplasty and 44%
after the second angioplasty. They achieved assisted primary patency
results of 80% in three postoperative years. They concluded that transluminal
angioplasty should be the initial method for this group of patients.
However, they also recommend surgery for restenosis after transluminal
angioplasty.28
Dunlop et al. demonstrated patency of 74% in grafts submitted to transluminal
angioplasty, with a limb salvage rate of 90% in four years.29
London et al. observed primary assisted patency of 65% in three
years.30 In our study, with an average
follow-up time of 15 months, only one patient evolved ischemic symptoms,
and this patient was submitted to a new transluminal angioplasty. Afterward,
the patient's symptoms improved. Two patients evolved with recurrence
and were submitted to surgery after presenting lesions that were unfavorable
to angioplasty. An asymptomatic obstruction was discovered that was
clinically followed. The limb salvage rate for the period was 100%.
Sanches et al. demonstrated that the observance of rigid inclusion criteria
(simple, single and non-recurrent lesions, < 15 mm in extension and
in venous grafts with a diameter of over > 3 mm) are important factors
in the success of transluminal angioplasty.31
In this study, there was no difference in the patency depending
on the location of the anastomosis site. In our study, observing similar
inclusion criteria and rigid exclusion criteria, it was possible to
perform the transluminal angioplasty in 100% of the cases and the result
of the procedure was considered solid in 89.5% and moderate in 10.5%
of the cases. This demonstrates the importance of these criteria in
the choice of candidate patients for this type of treatment.
Some authors recommend surgical treatment in the case of recurrence.12,28
It appears that the highest obstruction rate in this group can
indicate a greater aggressiveness of the disease in the patients. Marin
et al. demonstrated that some anatomopathological characteristics are
related to this phenomenon. The high level of initial thickening and
the presence of subintimal dissection are related to obstruction and
restenosis.32 Therefore, it appears that
the use of the endoluminal ultrasonography can help to define the most
favorable stenoses for the transluminal angioplasty.
The role of the use of the stent in transluminal angioplasty
of grafts has yet to be well-defined.33,34
Its use could potentially improve the patency results. However, there
are no studies proving the efficiency in this group of patients. Currently,
the use of the stent in the arterial infrainguinal segments has not
shown any benefits in comparison to isolated transluminal angioplasty.35,36
The atherectomy has been utilized as an alternative technique to the
transluminal angioplasty. However, its use is technically more laborious.
Its has a very rigid and large- caliber (8-10F) catheter, which complicates
its use in patients that suffer from stenosis of the distal arterial
segments. In addition to this, it is more frequently associated with
complications (6-11%), such as distal embolization, graft obstruction
and the formation of pseudoaneurysm.37-39
Recently, Engelke et al. published an initial study in which they utilized
a special catheter balloon with longitudinal sheets that were positioned
in glands along the balloon body. When the balloon is inflated, the
sheets protract to the outside and longitudinally cut the narrowed region.
This balloon was initially developed for the treatment of recurrent
lesions in coronary arteries that were previously treated through angioplasty
and stent placement. Its effects are related to the rupture in the fibroelastic
structure of these lesions affected by neointimal hyperplasia and prevention
of the elastic retraction and dilatation of the lesions, with a recuperation
of artery diameter that is more effective than that reached with a common
transluminal angioplasty. The technique was successful in 94% of the
patients studied and the primary and secondary patency reached in 12
and 18 months was 67% and 83%, respectively.40
In our study, observing the rigid inclusion and exclusion criteria described
above, we discovered that of all the transluminal angioplasties performed,
17 (89.5%) were considered to have a good arteriographic result, and
two (10.5%) a moderate result. In terms of complications, only three
patients evolved hematomas at the puncture site, and these hematomas
quickly healed themselves. The average hospital stay time was 32 hours.
With the average follow-up time of 15 months and a medium of 12 months,
13 (68.4%) angioplasties evolved with lower restenosis rates of 50%
and were clinically followed. Two patients were submitted to surgery
after presenting restenosis that was not favorable for angioplasty.
One patient was submitted to a new angioplasty with success. Another
patient evolved an asymptomatic obstruction of the graft. The limb salvage
rate for the study period was 100%.
CONCLUSION
Therefore, we conclude
that transluminal angioplasty represents a favorable method for the maintenance
of patency and the salvage of limbs in patients submitted to revascularization
of the lower limbs. Rigorous clinical and ultrasonographic follow-up, the precocious
identification of stenotic lesions that put the patency of the graft at risk and
the rigorous observation of morphological and anatomical criteria of these lesions
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