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Percutaneous laser thermal angioplasty: Results in peripheral arterial occlusions
680
CLINICAL RADIOLOGY
The main components of the proforma are: 1 A table of the mediastinal nodal groups as per the ATS classification with columns according to node size from <1 cm to >1.5 cm with a final column to chart the corresponding CT slice number. 2 Sections for tumour site and size, lung consolidation, and other lung pathology. 3 A space for qualifying comments about the scan including the diagnosed category - N2 negative, positive or intermediate. 4 Finally, the remainder of the proforma consists of a chart of several CT slice diagrams where the ATS classification is labelled to assist new reporters in the identification of the nodal groups. INCIDENCE OF UNSUSPECTED RENAL ARTERY STENOSIS IN PATIENTS WITH INTERMITTENT CLAUDICATION; IMPLICATIONS FOR MANAGEMENT WITH CAPTOPRIL A. H. CHOUDHRI, P. C. ROWLANDS, M. McCARTY, J. CLELAND and M. A. O. AL-KUTOUBI
St Mary's Hospital, London Recent work has suggested that Captopril is an appropriate therapy in patients with hypertension (HBP) and peripheral vascular disease (PVD). Acute renal failure in patients with renal artery stenosis (RAS) receiving Captopril is well recognised. However RAS can be silent. We studied the renal arteries of 30 consecutive patients with intermittent claudication referred for catheter aortography. Good views of the renal arteries were obtained by aortic injection of contrast via the same pigtail catheter used for the peripheral series of films; in most cases these were DSA images. Eighteen patients were men and the mean age was 70. The median serum creatinine was 112/xmol (range 42-901/xmol). Seven patients had HBP (BP>150/95). RAS was found in 15 patients; in four the disease was bilateral. One artery was blocked in three patients; of the rest, stenosis was considered severe in five, moderate in six and mild in one. One patient had bilateral fibromuscular hyperplasia. Serum creatinine and HBP did not predict the presence of RAS. We have shown that the incidence of RAS is high in patients with PVS. We would recommend that in those patients undergoing catheter aortography the renal arteries be imaged at the same sitting.
Complications included six vessel wall perforations, one popliteal thrombosis and one distal embolism. The probe detached in one case. To assess the beneficial effect of recanalising long occlusions the 1 year patency rates of the combined experience in Boston and Sheffield using laser thermal angioplasty have been calculated. In occlusions of 1-3 cm, 4-7 cm, and greater than 7 cm the results are 93%, 76% and 58% respectively. The 2-year patency rates in 42 Sheffield patients have also been calculated and are 73% overall. These results are somewhat better than conventional balloon angioplasty results reported in the literature. Although a randomised trial is necessary, the results imply that thermal vaporisation of atheroma contributes to improved patency rates. A RANDOMISED TRIAL OF LASER-ASSISTED ANGIOPLASTY
IN OCCLUDED FEMORO-POPLITEAL ARTERIES W. D. JEANS and P. MURPHY
University of Bristol, Bristol A randomised trial is being undertaken to assess(a) whether the use of a laser probe to make a passage through occluded femoro-popliteal segments allows occlusions to be passed more often than is possible with a guide wire and catheter before balloon angioplasty is undertaken, and (b) whether occluded segments passed using the laser probe stay patent for longer than those in which a laser is not used. Randomisation is by year of birth to one of two groups. In one group the laser probe is used first, and in the other the guide wire and catheter is passed first. In both groups, passage through the occlusion is followed by passage of a guide wire and a balloon catheter to dilate the occluded segment. In either group failure of the primary attempt allows the other technique to be used. Information concerning the patient's age, sex, relevant general medical disease, the indication for treatment, length and site of occlusions, the presence of calcification, the number of patent calf vessels, and the ankle pressures is recorded at the time of the procedure and patients are followed up to assess results at 1, 3 and 6 months. The results in 50 patients entered into the trial will be presented.
ANGIOPLASTY OF OCCLUDED VESSELS USING A FAST ROTATING TIP CATHETER M. R. REES and A. A. GEHANI
Killingbeck Hospital, Leeds THE CLINICAL IMPORTANCE OF ANGIOPLASTY IN RENAL TRANSPLANT ARTERY STENOSIS S. P. OLLIFF, A. SEVERN, H., WALTER and J. KARANI
King's College Hospital, London Hypertension and poor renal function are well-recognised complications in patients with a transplant kidney. Stenosis of the transplant artery is present and contributes to the dysfunction in 10 to 24% of cases. Other factors such as rejection, infection, obstruction and native renal disease must also be diagnosed and treated. The diagnosis of arterial stenosis depends on angiographic demonstration. Angioplasty was attempted in 30 cases in whom stenosis was shown. Successful balloon dilatation was achieved in 90% of cases. The clinical importance of angioplasty was assessed by review of the serum creatinine, blood pressure and anti-hypertensive therapy requirements in all cases. These parameters were compared immediately prior to and following angioplasty with longer term follow-up from 3 months to 2 years. Other complications leading to morbidity or mortality were also noted. The results will be presented and discussed. Technical factors such as the individual vascular anatomy prevented initial angioplasty in 15% of cases. Subsequent use of different catheters and balloons allowed later success in most cases. The choice of angioplasty equipment will be discussed with reference to these.
PERCUTANEOUS LASER THERMAL ANGIOPLASTY: RESULTS IN PERIPHERAL ARTERIAL OCCLUSIONS A-M. BELL and D. C. CUMBERLAND
Dynamic angioplasty using a fast rotating tip catheter (Kensey catheter) was carried out in 12 male patients with severe peripheral vascular disease. All the patients had intermittent claudication (range 30-300 metres) and one patient had rest pain with ischaemic changes. The lesions treated were: 10 femoro-popliteal occlusions (3-16 cm) and two iliac occlusions (2, 8 cm). Kensey catheterisation was carried out percutaneously using tip spin speeds of 40 000-90 000 rev/min. The catheter was flushed using a dextran, contrast and streptokinase mixture. Seven of the lesions were completely reopened, arterial dissections occurring in four and perforation in one patient. Two of the dissections were in the first two patients treated, with a now discontinued catheter design. The perforation occurred after the use of a laser when the lesion could not be opened by the Kensey catheter. Dissection was increased with calcified vessels (75%). No patient showed a drop in limb blood flow or Doppler, two patients showed no improvement in either. Follow-up results show that clinical improvement has been maintained at 6 months. The clinical improvement in three patients who did not have complete recanalisation may be due to increased collateral flow. These preliminary results indicate that dynamic atherectomy is an encouraging technique.
USE OF THE ATHERECTOMY CATHETER ON VENOUS STENOSES OF HAEMODIALYSIS SHUNTS P. JAQUES, M. M A U R O and F. M A D D U X
North Carolina Memorial Hospital, North Carolina, USA
Northern General Hospital, Sheffield A rounded metal-tipped laser fibre, the laser probe, has been developed to overcome the high incidence of vessel perforation produced by the bare laser fibre. This converts all the laser energy to heat. A total of 119 occlusions, 110 of which were in the femorallpopliteal segment, were recanalised using the laser probe, followed by conventional balloon angioplasty. The mean length of occlusion was 9 cm with a range of 1 to 35 cm. The primary success rate was 76%.
Arteriovenous shunts, with or without the interposition of prosthetic material, have proved extemely beneficial for patients on long term haemodialysis. Unfortunately, these shunts have a limited lifespan, with a 62-87% survival for a Gortex graft at 1 year. A major contributing cause for haemodialysis fistula failure is the the inexorable development of focal venous intimal hyperplasia, a natural response of the vein wall to arterialised flow. Balloon angioplasty has been successfully employed to manage these stenoses, but there is a high
CLINICAL RADIOLOGY
The main components of the proforma are: 1 A table of the mediastinal nodal groups as per the ATS classification with columns according to node size from <1 cm to >1.5 cm with a final column to chart the corresponding CT slice number. 2 Sections for tumour site and size, lung consolidation, and other lung pathology. 3 A space for qualifying comments about the scan including the diagnosed category - N2 negative, positive or intermediate. 4 Finally, the remainder of the proforma consists of a chart of several CT slice diagrams where the ATS classification is labelled to assist new reporters in the identification of the nodal groups. INCIDENCE OF UNSUSPECTED RENAL ARTERY STENOSIS IN PATIENTS WITH INTERMITTENT CLAUDICATION; IMPLICATIONS FOR MANAGEMENT WITH CAPTOPRIL A. H. CHOUDHRI, P. C. ROWLANDS, M. McCARTY, J. CLELAND and M. A. O. AL-KUTOUBI
St Mary's Hospital, London Recent work has suggested that Captopril is an appropriate therapy in patients with hypertension (HBP) and peripheral vascular disease (PVD). Acute renal failure in patients with renal artery stenosis (RAS) receiving Captopril is well recognised. However RAS can be silent. We studied the renal arteries of 30 consecutive patients with intermittent claudication referred for catheter aortography. Good views of the renal arteries were obtained by aortic injection of contrast via the same pigtail catheter used for the peripheral series of films; in most cases these were DSA images. Eighteen patients were men and the mean age was 70. The median serum creatinine was 112/xmol (range 42-901/xmol). Seven patients had HBP (BP>150/95). RAS was found in 15 patients; in four the disease was bilateral. One artery was blocked in three patients; of the rest, stenosis was considered severe in five, moderate in six and mild in one. One patient had bilateral fibromuscular hyperplasia. Serum creatinine and HBP did not predict the presence of RAS. We have shown that the incidence of RAS is high in patients with PVS. We would recommend that in those patients undergoing catheter aortography the renal arteries be imaged at the same sitting.
Complications included six vessel wall perforations, one popliteal thrombosis and one distal embolism. The probe detached in one case. To assess the beneficial effect of recanalising long occlusions the 1 year patency rates of the combined experience in Boston and Sheffield using laser thermal angioplasty have been calculated. In occlusions of 1-3 cm, 4-7 cm, and greater than 7 cm the results are 93%, 76% and 58% respectively. The 2-year patency rates in 42 Sheffield patients have also been calculated and are 73% overall. These results are somewhat better than conventional balloon angioplasty results reported in the literature. Although a randomised trial is necessary, the results imply that thermal vaporisation of atheroma contributes to improved patency rates. A RANDOMISED TRIAL OF LASER-ASSISTED ANGIOPLASTY
IN OCCLUDED FEMORO-POPLITEAL ARTERIES W. D. JEANS and P. MURPHY
University of Bristol, Bristol A randomised trial is being undertaken to assess(a) whether the use of a laser probe to make a passage through occluded femoro-popliteal segments allows occlusions to be passed more often than is possible with a guide wire and catheter before balloon angioplasty is undertaken, and (b) whether occluded segments passed using the laser probe stay patent for longer than those in which a laser is not used. Randomisation is by year of birth to one of two groups. In one group the laser probe is used first, and in the other the guide wire and catheter is passed first. In both groups, passage through the occlusion is followed by passage of a guide wire and a balloon catheter to dilate the occluded segment. In either group failure of the primary attempt allows the other technique to be used. Information concerning the patient's age, sex, relevant general medical disease, the indication for treatment, length and site of occlusions, the presence of calcification, the number of patent calf vessels, and the ankle pressures is recorded at the time of the procedure and patients are followed up to assess results at 1, 3 and 6 months. The results in 50 patients entered into the trial will be presented.
ANGIOPLASTY OF OCCLUDED VESSELS USING A FAST ROTATING TIP CATHETER M. R. REES and A. A. GEHANI
Killingbeck Hospital, Leeds THE CLINICAL IMPORTANCE OF ANGIOPLASTY IN RENAL TRANSPLANT ARTERY STENOSIS S. P. OLLIFF, A. SEVERN, H., WALTER and J. KARANI
King's College Hospital, London Hypertension and poor renal function are well-recognised complications in patients with a transplant kidney. Stenosis of the transplant artery is present and contributes to the dysfunction in 10 to 24% of cases. Other factors such as rejection, infection, obstruction and native renal disease must also be diagnosed and treated. The diagnosis of arterial stenosis depends on angiographic demonstration. Angioplasty was attempted in 30 cases in whom stenosis was shown. Successful balloon dilatation was achieved in 90% of cases. The clinical importance of angioplasty was assessed by review of the serum creatinine, blood pressure and anti-hypertensive therapy requirements in all cases. These parameters were compared immediately prior to and following angioplasty with longer term follow-up from 3 months to 2 years. Other complications leading to morbidity or mortality were also noted. The results will be presented and discussed. Technical factors such as the individual vascular anatomy prevented initial angioplasty in 15% of cases. Subsequent use of different catheters and balloons allowed later success in most cases. The choice of angioplasty equipment will be discussed with reference to these.
PERCUTANEOUS LASER THERMAL ANGIOPLASTY: RESULTS IN PERIPHERAL ARTERIAL OCCLUSIONS A-M. BELL and D. C. CUMBERLAND
Dynamic angioplasty using a fast rotating tip catheter (Kensey catheter) was carried out in 12 male patients with severe peripheral vascular disease. All the patients had intermittent claudication (range 30-300 metres) and one patient had rest pain with ischaemic changes. The lesions treated were: 10 femoro-popliteal occlusions (3-16 cm) and two iliac occlusions (2, 8 cm). Kensey catheterisation was carried out percutaneously using tip spin speeds of 40 000-90 000 rev/min. The catheter was flushed using a dextran, contrast and streptokinase mixture. Seven of the lesions were completely reopened, arterial dissections occurring in four and perforation in one patient. Two of the dissections were in the first two patients treated, with a now discontinued catheter design. The perforation occurred after the use of a laser when the lesion could not be opened by the Kensey catheter. Dissection was increased with calcified vessels (75%). No patient showed a drop in limb blood flow or Doppler, two patients showed no improvement in either. Follow-up results show that clinical improvement has been maintained at 6 months. The clinical improvement in three patients who did not have complete recanalisation may be due to increased collateral flow. These preliminary results indicate that dynamic atherectomy is an encouraging technique.
USE OF THE ATHERECTOMY CATHETER ON VENOUS STENOSES OF HAEMODIALYSIS SHUNTS P. JAQUES, M. M A U R O and F. M A D D U X
North Carolina Memorial Hospital, North Carolina, USA
Northern General Hospital, Sheffield A rounded metal-tipped laser fibre, the laser probe, has been developed to overcome the high incidence of vessel perforation produced by the bare laser fibre. This converts all the laser energy to heat. A total of 119 occlusions, 110 of which were in the femorallpopliteal segment, were recanalised using the laser probe, followed by conventional balloon angioplasty. The mean length of occlusion was 9 cm with a range of 1 to 35 cm. The primary success rate was 76%.
Arteriovenous shunts, with or without the interposition of prosthetic material, have proved extemely beneficial for patients on long term haemodialysis. Unfortunately, these shunts have a limited lifespan, with a 62-87% survival for a Gortex graft at 1 year. A major contributing cause for haemodialysis fistula failure is the the inexorable development of focal venous intimal hyperplasia, a natural response of the vein wall to arterialised flow. Balloon angioplasty has been successfully employed to manage these stenoses, but there is a high