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The Merits of Percutaneous Transluminal Angioplasty of a Superficial Femoral Artery Stenosis via a Retrograde Popliteal Artery Approach
The Merits of Percutaneous Transluminal Angioplasty of a Superficial Femoral Artery Stenosis via a Retrograde Popliteal Artery ro roach' Peter A. Villas, MD, PhD Gary Cohen, MD Ajay Goyal, MD Samuel G. Putnam Ill, MD David Ball, DO
Index terms: Angioplasty, femoral Arteries, angioplasty
JVIR 1999; 10:325-328
,
A common femoral artery approach is routinely used for percutaneous management of lower extremity vascular disease. However, there are occasions when this approach is impractical because of a variety of circumstances including proximal or ostial femoral artery lesions, severe atheromatous femoral artery lesions preventing puncture, infections in the region of the groin a t the level of the funoral artery puncture site, andlor severe scarring with resultant fibrosis from previous surgery in the region of the fanoral artery (1).These circumstances make it difficult, if not impossible, to safely introduce a vascular sheath and gain access to the lesion. Therefore, a retrograde ~ o ~ l i t earterial al aproach becomes extremely valuable as a technique for allowing treatment of these lesions. We describe a patient with left lower extremity pain at rest and no available femoral artery aCcess bilaterally who undenvent successful treatment of a superficial by means of percutaneous angiO~last~ via the p0plitea1
CASE REPORT From the Department of Diagnostic Imaging, Temple University Hospital, Broad and Ontario Streets, Philadelphia, PA 19140, Received June 6,1998; revision requested July 9; revision received and accepted September 15. Address correspondence to G.C.
o SCVIR, 1999
A 4kyear-old man had a previous myocardial infarction in 1996 (2 years prior to the current procedure). At that time, the patient undement thrombolytic therapy with tissue plasminogen activator. Concurrently, the patient's cardiologist identified, at ar-
teriography, multiple occlusions in both lower extremity arterial systems, the right worse than the left. On further questioning a t that time, the patient stated that he was only able to walk approximately a halfblock before right leg pain and cramping occurred, followed soon thereafter by similar symptoms involving the left lower extremity. Currently, the patient experiences left lower extremity pain a t rest. The patient's medical and surgical histories were significant for atherosclerosis resulting in placement of a left common iliac artery ,tent followed by an aortobifemoral bypass and, lastly, a right femoralpopliteal bypass. ~h~ patient had a smoking history of 2 packs per day for 20 years. A diagnostic lower extremity arteriogram had been obtained from a left brachial artery approach. A short segment 90% ste,,,is was identified in the adductor canal region of the left superficial femoral artery. There was distal reconstitution of an above-the-knee popliteal artery. Below the knee, there was a small posterior tibial artery that was occluded in the distal calf. The peroneal artery was patent to the ankle, which supplied a small anterior division and a ~ O S terior division that reconstituted a moderate-sized plantar arch. The decided approach was a left retrograde popliteal artery puncture. Physical evaluation of the left lower extremity revealed a 2+ palpable common femoral arterial
325
326
Merits of Percutaneous Transluminal Angioplasty
March 1999 JVIR
Figure 1. US with Doppler demonstrating the relationship of the popliteal artery (A) and vein (V).
pulse and a markedly diminished popliteal pulse, and no palpable dorsalis pedis or posterior tibialis pulse. Despite the presence of a common femoral arterial pulse, the several healed surgical incisions noted in the left groin from previous catherizations and the aortobifemoral bypass prohibited antegrade access. Neither extremity appeared edematous or cyanotic. The right groin surgical incision had a small area of erythema and swelling, producing an exudate, and was tender to palpation. The patient was placed in the prone position and prepared and draped in the usual sterile manner. The left popliteal artery was accessed freehand under direct ultrasonographic (US) visualization of the artery with use of a n Acuson 128 XP110 with a 7-MHz Acuson #7 probe (Acuson, Mountain View, CA) (Fig 1). A 21-gauge needle angled a t nearly 90" to the popliteal artery immediately above the femoral-tibial joint space was then used to cannulate the popliteal artery, and a platinum-tipped 0.018-inch guide wire (Cook, Bloomington, IN) was easily advanced into the popliteal artery and advanced to the superficial femoral artery in a retrograde manner. The needle was exchanged for a 3-F dilator and sequential vascular dilation was performed to 5 F. A 5-F vascular sheath was inserted and an 0.035-inch Bentson wire (Cook) was then advanced beyond
the 4-cm-long region of stenosis a t the level of the adductor canal. The Bentson wire was then exchanged for a n 0.035-inch Amplatz Super Stiff wire (Medi-tech/Boston Scientific, Watertown, MA). At this time, 5,000 U of intravenously administered heparin, 10 mg of Procardia sublingual (Novapharm USA, Schaumburg, IL), and 1 g of Ancef IV (Eli-Lilly, Indianapolis, IN) were given to the patient. Intravenous antibiotics that are commonly given prophylactically a t our institution during procedures involving stent placement were administered in anticipation of stent placement. Roadmapping identified the lesion (Fig 2) and, under fluoroscopic guidance, a 6-mm Courier angioplasty balloon (Medi-tech/Boston Scientific) was inflated within the stenosed arterial segment until the waist was relieved. Nonionic contrast material was injected through the sheath and a intimal flap was seen over the site of angioplasty (Fig 3). Follow-up retrograde digital subtraction angiography identified a significant flow-restricting, postdilation dissection that was treated with a 6-mm percutaneous transluminal angioplasty (PTA) balloon inflation for 60 seconds. Pressure measurements across this dissection could not be accurately assessed because of the proximity of the sheath, therefore, we elected to treat the flap. The postinflation arteriogram revealed no residual stenosis, dissection, or flap and the wire was removed (Fig 4). Two hours later, after normalization of blood coagulation studies, the 5-F sheath was removed and hemostasis was achieved with manual compression. The patient remained asymptomatic in the left lower extremity for 3 months after the procedure and was lost to further follow-up.
1 DISCUSSION Several reports have been published on the use of the popliteal artery as an access site for treatment of superficial femoral artery stenoses (2-7). The popliteal approach improved the early success
of one group's original antegrade access by 6% and increased by nearly 20% the number of patients considered technically feasible for PTA in the femoral artery (6). There have been no reported significant differences in success or complications between popliteal and femoral approaches for superficial femoral artery lesions (6). US guidance eliminates the potential complication of a n arteriovenous fistula in the popliteal region. Popliteal hematomas have been successfullv minimized by delaying the administration of anticoagulants until after hemostasis has been achieved (3). Vasospasm was encountered during puncture of the popliteal artery in one report (8). We used US guidance and knowledge of the relationship of the popliteal artery and vein to one another to minimize the risk of a complication from the puncture into the popliteal artery. The anatomy of this relationship has been reported in cadaver studies in the literature (9). It was found that the artery and vein are enclosed in a common sheath (9). In this article, the authors divided the popliteal region into five levels (9). Our level of access, approximately 1-2 cm above the femorotibial joint space, corres ~ o n d e dto level 2 access (9). . . Care was taken during the puncture because of the closeness of the arterv and vein to one another a t level 2, as the popliteal artery lies medial (50%) or anteromedial(48%) to the popliteal vein (9). In addition, the level of the access within the popliteal artery must be determined before puncture because the difficulty of compression after withdrawal of the vascular sheath may lead to the formation of either a hematoma or arteriovenous fistula. We chose to puncture the popliteal artery under US visualization approximately 1-2 cm above the level of the femorotibial joint so that adequate compression after vascular sheath removal could be obtained. The utility of a micropuncture system allowed for minimal entry trauma to the popliteal artery and was followed by placement of a 5-F vascular sheath. The left popliteal artery was ac-
Villas et a1
327
Volume 10 Number 3
Figures 2-4.
(2) Roadmap digital subtraction angiogram revealing the area of stenosis proximal to the adductor canal (arrowhead). PTA was performed from the mid-superficial femoral artery (ie, the superior portion of the image) to the large lateral collateral branch located proximal to the popliteal artery. (3) Roadmap digital subtraction angiogram demonstrating the intima1 flap created after angioplasty (arrowhead). (4) Final roadmap digital subtraction angiogram no longer demonstrating the intimal flap (arrowhead).
cessed in a retrograde manner so that repair of the patient's previously diagnosed stenosis in the left superficial femoral artery could be performed. A brachial artery approach had been performed for the diagnostic study; however, because this patient had innumerable known radial and ulnar arterial occlusions bilaterally (prior arteriogram results) we elected to minimize our access to the upper extremity. In our experience, there is no significant difference in the occurrence of either a hematoma or arteriovenous fistula when accessing the brachial or popliteal artery. Furthermore, the brachial and pop-
liteal arteries are technically easy to access under direct US visualization. The postdilation intimal flap created a dilemma for us; we were reluctant to insert a stent in this location, especially because this was the first angioplasty of this lesion for the patient. It has been reported that long-term patency of stent placement in the superficial femoral artery is poor, with major complications occurring 16.7% of the time (10). Additionally, stent placement would have necessitated increasing the sheath size. Therefore, we used a balloon inflated for approximately 60 seconds a t the level of the inti-
ma1 flap to, in effect, tack down the flap to the remaining portion of the arterial wall. This technique has been reported previously with use of perfusion balloon catheters and worked well for our case (11). . . Therefore, micropuncture systems, US guidance, and the knowledge of popliteal fossa anatomy made this procedure a safe and viable option for this patient. References 1. Henry M, Amicabile C, Amor M, et al. Peripheral arterial angioplasty: value of the popliteal approach. Archives des Maladies du Coeur at des Vaisseaux 1993; 86:463-469.
328
Merits of Percutaneous Transluminal Angioplasty
March 1999 JVIR
2. Breen D, Morgan R, Buckenham T. Transpopliteal angioplasty of combined iliofemoral occlusions. Clin Radiol 1993; 47:193-195. 3. Tonnesen KH, Sager P, Karle A, Henriksen L, Jorgensen B. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol 1988; 11:127-131. 4. Zaitoun R, Iyer SS, Lenin RF, et al. Percutaneous popliteal approach for angioplasty of superficial femoral artery occlusions. Cathet Cardiovasc Diagn 1990; 21:154-158. 5. Heenan SD, Vinnicombe SJ, Buckenham TM, et al. Percutaneous transluminal angioplasty by a retro-
grade subintimal transpopliteal approach. Clin Radiol 1994; 49:824827 w/discussion pp. 827-828. 6. Matsi PJ, Manninen HI, Soder HK, et al. Percutaneous transluminal angioplasty in femoral artery occlusions: primary and long-term results in 107 claudicant patients using femoral and popliteal catheterization techniques. Clin Radiol 1995; 50:237-244. 7. Sievert H, Ibers H, Scherer D, Spies HF, Sultan N. Retrograde catheter recanalization of long range occlusion of the superficial femoral artery. Deutsche Medizinische Wochenschrift 1994; 119:948-950. 8. McCullough KM. Retrograde transpopliteal salvage of the failed
antegrade transfemoral angioplasty. Australian Radiol 1993; 37:329-331. 9. Trigaux JP, Van Beers B, Wispelaere JF. Anatomic relationship between the popliteal artery and vein: a guide to accurate angiographic puncture. AJR 1990; 157: 1259-1262. 10. Martin EC, Katzen BT, Benenati JF, et al. Multicenter trial of the Wallstent in the iliac and femoral arteries. JVIR 1995; 62343-849. 11. Manninen HI, Soder HK, Matsi PJ, Kaukanen E, Rasanen H, Yang X. Prolonged dilation improves an unsatisfactory primary result of femoropopliteal artery angioplasty: usefulness of a perfusion balloon catheter. JVIR 1997; 8:627-632.
Index terms: Angioplasty, femoral Arteries, angioplasty
JVIR 1999; 10:325-328
,
A common femoral artery approach is routinely used for percutaneous management of lower extremity vascular disease. However, there are occasions when this approach is impractical because of a variety of circumstances including proximal or ostial femoral artery lesions, severe atheromatous femoral artery lesions preventing puncture, infections in the region of the groin a t the level of the funoral artery puncture site, andlor severe scarring with resultant fibrosis from previous surgery in the region of the fanoral artery (1).These circumstances make it difficult, if not impossible, to safely introduce a vascular sheath and gain access to the lesion. Therefore, a retrograde ~ o ~ l i t earterial al aproach becomes extremely valuable as a technique for allowing treatment of these lesions. We describe a patient with left lower extremity pain at rest and no available femoral artery aCcess bilaterally who undenvent successful treatment of a superficial by means of percutaneous angiO~last~ via the p0plitea1
CASE REPORT From the Department of Diagnostic Imaging, Temple University Hospital, Broad and Ontario Streets, Philadelphia, PA 19140, Received June 6,1998; revision requested July 9; revision received and accepted September 15. Address correspondence to G.C.
o SCVIR, 1999
A 4kyear-old man had a previous myocardial infarction in 1996 (2 years prior to the current procedure). At that time, the patient undement thrombolytic therapy with tissue plasminogen activator. Concurrently, the patient's cardiologist identified, at ar-
teriography, multiple occlusions in both lower extremity arterial systems, the right worse than the left. On further questioning a t that time, the patient stated that he was only able to walk approximately a halfblock before right leg pain and cramping occurred, followed soon thereafter by similar symptoms involving the left lower extremity. Currently, the patient experiences left lower extremity pain a t rest. The patient's medical and surgical histories were significant for atherosclerosis resulting in placement of a left common iliac artery ,tent followed by an aortobifemoral bypass and, lastly, a right femoralpopliteal bypass. ~h~ patient had a smoking history of 2 packs per day for 20 years. A diagnostic lower extremity arteriogram had been obtained from a left brachial artery approach. A short segment 90% ste,,,is was identified in the adductor canal region of the left superficial femoral artery. There was distal reconstitution of an above-the-knee popliteal artery. Below the knee, there was a small posterior tibial artery that was occluded in the distal calf. The peroneal artery was patent to the ankle, which supplied a small anterior division and a ~ O S terior division that reconstituted a moderate-sized plantar arch. The decided approach was a left retrograde popliteal artery puncture. Physical evaluation of the left lower extremity revealed a 2+ palpable common femoral arterial
325
326
Merits of Percutaneous Transluminal Angioplasty
March 1999 JVIR
Figure 1. US with Doppler demonstrating the relationship of the popliteal artery (A) and vein (V).
pulse and a markedly diminished popliteal pulse, and no palpable dorsalis pedis or posterior tibialis pulse. Despite the presence of a common femoral arterial pulse, the several healed surgical incisions noted in the left groin from previous catherizations and the aortobifemoral bypass prohibited antegrade access. Neither extremity appeared edematous or cyanotic. The right groin surgical incision had a small area of erythema and swelling, producing an exudate, and was tender to palpation. The patient was placed in the prone position and prepared and draped in the usual sterile manner. The left popliteal artery was accessed freehand under direct ultrasonographic (US) visualization of the artery with use of a n Acuson 128 XP110 with a 7-MHz Acuson #7 probe (Acuson, Mountain View, CA) (Fig 1). A 21-gauge needle angled a t nearly 90" to the popliteal artery immediately above the femoral-tibial joint space was then used to cannulate the popliteal artery, and a platinum-tipped 0.018-inch guide wire (Cook, Bloomington, IN) was easily advanced into the popliteal artery and advanced to the superficial femoral artery in a retrograde manner. The needle was exchanged for a 3-F dilator and sequential vascular dilation was performed to 5 F. A 5-F vascular sheath was inserted and an 0.035-inch Bentson wire (Cook) was then advanced beyond
the 4-cm-long region of stenosis a t the level of the adductor canal. The Bentson wire was then exchanged for a n 0.035-inch Amplatz Super Stiff wire (Medi-tech/Boston Scientific, Watertown, MA). At this time, 5,000 U of intravenously administered heparin, 10 mg of Procardia sublingual (Novapharm USA, Schaumburg, IL), and 1 g of Ancef IV (Eli-Lilly, Indianapolis, IN) were given to the patient. Intravenous antibiotics that are commonly given prophylactically a t our institution during procedures involving stent placement were administered in anticipation of stent placement. Roadmapping identified the lesion (Fig 2) and, under fluoroscopic guidance, a 6-mm Courier angioplasty balloon (Medi-tech/Boston Scientific) was inflated within the stenosed arterial segment until the waist was relieved. Nonionic contrast material was injected through the sheath and a intimal flap was seen over the site of angioplasty (Fig 3). Follow-up retrograde digital subtraction angiography identified a significant flow-restricting, postdilation dissection that was treated with a 6-mm percutaneous transluminal angioplasty (PTA) balloon inflation for 60 seconds. Pressure measurements across this dissection could not be accurately assessed because of the proximity of the sheath, therefore, we elected to treat the flap. The postinflation arteriogram revealed no residual stenosis, dissection, or flap and the wire was removed (Fig 4). Two hours later, after normalization of blood coagulation studies, the 5-F sheath was removed and hemostasis was achieved with manual compression. The patient remained asymptomatic in the left lower extremity for 3 months after the procedure and was lost to further follow-up.
1 DISCUSSION Several reports have been published on the use of the popliteal artery as an access site for treatment of superficial femoral artery stenoses (2-7). The popliteal approach improved the early success
of one group's original antegrade access by 6% and increased by nearly 20% the number of patients considered technically feasible for PTA in the femoral artery (6). There have been no reported significant differences in success or complications between popliteal and femoral approaches for superficial femoral artery lesions (6). US guidance eliminates the potential complication of a n arteriovenous fistula in the popliteal region. Popliteal hematomas have been successfullv minimized by delaying the administration of anticoagulants until after hemostasis has been achieved (3). Vasospasm was encountered during puncture of the popliteal artery in one report (8). We used US guidance and knowledge of the relationship of the popliteal artery and vein to one another to minimize the risk of a complication from the puncture into the popliteal artery. The anatomy of this relationship has been reported in cadaver studies in the literature (9). It was found that the artery and vein are enclosed in a common sheath (9). In this article, the authors divided the popliteal region into five levels (9). Our level of access, approximately 1-2 cm above the femorotibial joint space, corres ~ o n d e dto level 2 access (9). . . Care was taken during the puncture because of the closeness of the arterv and vein to one another a t level 2, as the popliteal artery lies medial (50%) or anteromedial(48%) to the popliteal vein (9). In addition, the level of the access within the popliteal artery must be determined before puncture because the difficulty of compression after withdrawal of the vascular sheath may lead to the formation of either a hematoma or arteriovenous fistula. We chose to puncture the popliteal artery under US visualization approximately 1-2 cm above the level of the femorotibial joint so that adequate compression after vascular sheath removal could be obtained. The utility of a micropuncture system allowed for minimal entry trauma to the popliteal artery and was followed by placement of a 5-F vascular sheath. The left popliteal artery was ac-
Villas et a1
327
Volume 10 Number 3
Figures 2-4.
(2) Roadmap digital subtraction angiogram revealing the area of stenosis proximal to the adductor canal (arrowhead). PTA was performed from the mid-superficial femoral artery (ie, the superior portion of the image) to the large lateral collateral branch located proximal to the popliteal artery. (3) Roadmap digital subtraction angiogram demonstrating the intima1 flap created after angioplasty (arrowhead). (4) Final roadmap digital subtraction angiogram no longer demonstrating the intimal flap (arrowhead).
cessed in a retrograde manner so that repair of the patient's previously diagnosed stenosis in the left superficial femoral artery could be performed. A brachial artery approach had been performed for the diagnostic study; however, because this patient had innumerable known radial and ulnar arterial occlusions bilaterally (prior arteriogram results) we elected to minimize our access to the upper extremity. In our experience, there is no significant difference in the occurrence of either a hematoma or arteriovenous fistula when accessing the brachial or popliteal artery. Furthermore, the brachial and pop-
liteal arteries are technically easy to access under direct US visualization. The postdilation intimal flap created a dilemma for us; we were reluctant to insert a stent in this location, especially because this was the first angioplasty of this lesion for the patient. It has been reported that long-term patency of stent placement in the superficial femoral artery is poor, with major complications occurring 16.7% of the time (10). Additionally, stent placement would have necessitated increasing the sheath size. Therefore, we used a balloon inflated for approximately 60 seconds a t the level of the inti-
ma1 flap to, in effect, tack down the flap to the remaining portion of the arterial wall. This technique has been reported previously with use of perfusion balloon catheters and worked well for our case (11). . . Therefore, micropuncture systems, US guidance, and the knowledge of popliteal fossa anatomy made this procedure a safe and viable option for this patient. References 1. Henry M, Amicabile C, Amor M, et al. Peripheral arterial angioplasty: value of the popliteal approach. Archives des Maladies du Coeur at des Vaisseaux 1993; 86:463-469.
328
Merits of Percutaneous Transluminal Angioplasty
March 1999 JVIR
2. Breen D, Morgan R, Buckenham T. Transpopliteal angioplasty of combined iliofemoral occlusions. Clin Radiol 1993; 47:193-195. 3. Tonnesen KH, Sager P, Karle A, Henriksen L, Jorgensen B. Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery. Cardiovasc Intervent Radiol 1988; 11:127-131. 4. Zaitoun R, Iyer SS, Lenin RF, et al. Percutaneous popliteal approach for angioplasty of superficial femoral artery occlusions. Cathet Cardiovasc Diagn 1990; 21:154-158. 5. Heenan SD, Vinnicombe SJ, Buckenham TM, et al. Percutaneous transluminal angioplasty by a retro-
grade subintimal transpopliteal approach. Clin Radiol 1994; 49:824827 w/discussion pp. 827-828. 6. Matsi PJ, Manninen HI, Soder HK, et al. Percutaneous transluminal angioplasty in femoral artery occlusions: primary and long-term results in 107 claudicant patients using femoral and popliteal catheterization techniques. Clin Radiol 1995; 50:237-244. 7. Sievert H, Ibers H, Scherer D, Spies HF, Sultan N. Retrograde catheter recanalization of long range occlusion of the superficial femoral artery. Deutsche Medizinische Wochenschrift 1994; 119:948-950. 8. McCullough KM. Retrograde transpopliteal salvage of the failed
antegrade transfemoral angioplasty. Australian Radiol 1993; 37:329-331. 9. Trigaux JP, Van Beers B, Wispelaere JF. Anatomic relationship between the popliteal artery and vein: a guide to accurate angiographic puncture. AJR 1990; 157: 1259-1262. 10. Martin EC, Katzen BT, Benenati JF, et al. Multicenter trial of the Wallstent in the iliac and femoral arteries. JVIR 1995; 62343-849. 11. Manninen HI, Soder HK, Matsi PJ, Kaukanen E, Rasanen H, Yang X. Prolonged dilation improves an unsatisfactory primary result of femoropopliteal artery angioplasty: usefulness of a perfusion balloon catheter. JVIR 1997; 8:627-632.