Annals of the Royal College of Surgeons of England (1992) vol. 74, 265-268
Consequences of immediate failure of percutaneous transluminal angioplasty M W J Armstrong
MB BS
Senior House Officer
E P H Torrie FRCR Consultant Radiologist R B Galland MD FRCS Consultant Surgeon Departments of Surgery and Radiology, Royal Berkshire Hospital, Reading Key words: Angioplasty; Complications Percutaneous transluminal angioplasty (PTA) is often used for patients who would not previously have been treated, due for example, to their poor general condition or their symptoms being relatively mild. The approximate overall initial success and complication rates are 80% and 10%, respectively. Iliac angioplasties fare rather better than superficial femoral dilatations. There is little information on the outcome of those patients in whom the procedure cannot be completed satisfactorily or who have complications. From 1985 to December 1990, 318 PTAs have been attempted on our unit, the majority within the last 3 years. In 53 (17%) the dilatation was not carried out, due to inability to position the guidewire (31) or balloon (16) satisfactorily, to disease progression (3) or systemic problems (3). None of these patients was made worse and 10 subsequently had a successful angioplasty. Complications occurred in 28 (9%). These included distal embolisation (10), bleeding (9), dissection (1), thrombotic occlusion (4) and vessel rupture (4). Complications were more common after superficial femoral, compared with iliac angioplasty (P < 0.02, x2 test). Eight patients with occlusion or embolus were treated with thrombolysis, five successfully. Three of these patients, and seven others, had surgical intervention (three within 6 h of angioplasty). Ten patients were treated conservatively, one died. Of the 28 patients who sustained complications, 27 were improved compared with their status before angioplasty, once their complication had been dealt with. PTA is a generally safe procedure and when complications occur most can be dealt with effectively.
Correspondence to: Mr R B Galland, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 SAN
Increasing numbers of patients are undergoing percutaneous dilatation of arterial stenoses or occlusions. Three-year patency rates of approximately 85% after aorto-iliac and 65% after femoropopliteal angioplasty can be expected (1). Some angioplasties will be performed instead of surgical reconstructions. However, many of the patients treated by angioplasty would have previously been managed conservatively (2,3), either because their symptoms were relatively mild or they were unfit for a surgical reconstruction. It is therefore important to know the outcome of those patients in whom the procedure fails. The angioplasty may be considered unsuccessful if it cannot be completed satisfactorily or if complications occur. The latter may only become apparent after successful completion of the angioplasty. Nevertheless, the patient may require further treatment, with a correspondingly increased length of hospital stay. Therefore, the procedure can be regarded as being, at least in part, unsuccessful. This study describes the outcome of those patients who sustain an immediate angioplasty failure.
Patients and methods Of those patients presenting to us with occlusive arterial disease, angioplasty, as the first line of treatment, is attempted in approximately 25%. From 1985 until the end of December 1990, 318 angioplasties were attempted in our department. These included 88 iliac and 230 femoropopliteal angioplasties. In 67% they were performed for intermittent claudication, the remainder being for rest pain, ulceration or gangrene. The male to
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Table I. Reasons for inability to complete angioplasty
female ratio was 2:1 and the median age of the patients treated was 67 years. All of the iliac lesions were stenoses; angioplasty was not attempted for iliac occlusions. On the other hand, 54% of the femoropopliteal lesions were stenoses, the remainder being complete occlusions. In 7% the occlusions were >5 cm in length. No vein angioplasties were performed in this series. The procedures were performed under local anaesthesia with a single planned overnight stay in hospital. After the angioplasty, patients were managed on a general surgical ward. Statistical analysis was performed using the x2 test.
Guidewire Unable to cross lesion Unable to enter correct artery Local dissection Perforation Balloon Unable to cross lesion Unable to dilate lesion Burst Miscellaneous Disease progression Artery not entered, patient obese Systemic complications Total
Results It was not possible to complete the procedure in 53 cases (17%). However, in six patients this was due to reasons unassociated with the site of the lesion (Table I), and these have therefore been excluded from the statistical analysis. The immediate success rate has remained fairly constant over the 6 years of the study. Complications were significantly more likely to occur when dealing with femoropopliteal compared with iliac lesions. Overall, the immediate failure rate was also significantly higher in distal compared with proximal lesions (Table II). Failure was no more likely in femoropopliteal occlusions compared with stenoses.
10 5 1 3 1
2 53
Occlusion
A total of 14 patients developed either thrombosis at the site of the angioplasty (four) or distal embolisation (ten). Of these, eight patients were treated with low-dose IAT, five successfully. The three patients in whom IAT failed and three others underwent an operation (five local or distant embolectomy and one femoropopliteal bypass). One patient was noted to have a tiny embolus in a calf vessel after a superficial femoral artery angioplasty. She was treated conservatively as all of her peripheral pulses were present, and her Doppler pressure had risen following the angioplasty. A total of 13 patients remain well and are symptomatically improved at a median follow-up of 12 months (range 4-32 months). The other patient reoccluded his superficial femoral artery 8 months later and then had a femoropopliteal bypass.
Inability to complete procedure The reasons for the procedure being abandoned before completion are shown in Table I. In all, three patients were noted to have progression of their disease since the original intravenous digital subtraction angiogram (IV DSA). These occurred early in our experience and we would now treat these with intraarterial thrombolysis (IAT) and proceed to angioplasty as appropriate (4,5). None of the patients was made worse by the failure to complete the procedure and 10 subsequently went on to have a successful angioplasty.
Bleeding from puncture site In all, nine patients developed haematomas after what was initially thought to be a successful angioplasty. Two required operation to suture the catheter entry site. One other patient, who had also had IAT, arrested and died on the way to the operating theatre. This case has been described elsewhere (4). The remaining patients were treated conservatively.
Complications In each of the patients who developed a complication the dilatation had been achieved satisfactorily.
Table II. Failure of PTA, related to site of occlusion or stenosis
(n = 226)
Iliac lesions (n = 86)
39 26 65
8 2 10
Femoropopliteal lesions Procedure not completed Complications Overall immediate failure
9 9 7 6
NS P < 0.02 P
Consequences of immediate failure of percutaneous transluminal angioplasty M W J Armstrong
MB BS
Senior House Officer
E P H Torrie FRCR Consultant Radiologist R B Galland MD FRCS Consultant Surgeon Departments of Surgery and Radiology, Royal Berkshire Hospital, Reading Key words: Angioplasty; Complications Percutaneous transluminal angioplasty (PTA) is often used for patients who would not previously have been treated, due for example, to their poor general condition or their symptoms being relatively mild. The approximate overall initial success and complication rates are 80% and 10%, respectively. Iliac angioplasties fare rather better than superficial femoral dilatations. There is little information on the outcome of those patients in whom the procedure cannot be completed satisfactorily or who have complications. From 1985 to December 1990, 318 PTAs have been attempted on our unit, the majority within the last 3 years. In 53 (17%) the dilatation was not carried out, due to inability to position the guidewire (31) or balloon (16) satisfactorily, to disease progression (3) or systemic problems (3). None of these patients was made worse and 10 subsequently had a successful angioplasty. Complications occurred in 28 (9%). These included distal embolisation (10), bleeding (9), dissection (1), thrombotic occlusion (4) and vessel rupture (4). Complications were more common after superficial femoral, compared with iliac angioplasty (P < 0.02, x2 test). Eight patients with occlusion or embolus were treated with thrombolysis, five successfully. Three of these patients, and seven others, had surgical intervention (three within 6 h of angioplasty). Ten patients were treated conservatively, one died. Of the 28 patients who sustained complications, 27 were improved compared with their status before angioplasty, once their complication had been dealt with. PTA is a generally safe procedure and when complications occur most can be dealt with effectively.
Correspondence to: Mr R B Galland, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading RG1 SAN
Increasing numbers of patients are undergoing percutaneous dilatation of arterial stenoses or occlusions. Three-year patency rates of approximately 85% after aorto-iliac and 65% after femoropopliteal angioplasty can be expected (1). Some angioplasties will be performed instead of surgical reconstructions. However, many of the patients treated by angioplasty would have previously been managed conservatively (2,3), either because their symptoms were relatively mild or they were unfit for a surgical reconstruction. It is therefore important to know the outcome of those patients in whom the procedure fails. The angioplasty may be considered unsuccessful if it cannot be completed satisfactorily or if complications occur. The latter may only become apparent after successful completion of the angioplasty. Nevertheless, the patient may require further treatment, with a correspondingly increased length of hospital stay. Therefore, the procedure can be regarded as being, at least in part, unsuccessful. This study describes the outcome of those patients who sustain an immediate angioplasty failure.
Patients and methods Of those patients presenting to us with occlusive arterial disease, angioplasty, as the first line of treatment, is attempted in approximately 25%. From 1985 until the end of December 1990, 318 angioplasties were attempted in our department. These included 88 iliac and 230 femoropopliteal angioplasties. In 67% they were performed for intermittent claudication, the remainder being for rest pain, ulceration or gangrene. The male to
266
M WJ7 Armstrong et al.
Table I. Reasons for inability to complete angioplasty
female ratio was 2:1 and the median age of the patients treated was 67 years. All of the iliac lesions were stenoses; angioplasty was not attempted for iliac occlusions. On the other hand, 54% of the femoropopliteal lesions were stenoses, the remainder being complete occlusions. In 7% the occlusions were >5 cm in length. No vein angioplasties were performed in this series. The procedures were performed under local anaesthesia with a single planned overnight stay in hospital. After the angioplasty, patients were managed on a general surgical ward. Statistical analysis was performed using the x2 test.
Guidewire Unable to cross lesion Unable to enter correct artery Local dissection Perforation Balloon Unable to cross lesion Unable to dilate lesion Burst Miscellaneous Disease progression Artery not entered, patient obese Systemic complications Total
Results It was not possible to complete the procedure in 53 cases (17%). However, in six patients this was due to reasons unassociated with the site of the lesion (Table I), and these have therefore been excluded from the statistical analysis. The immediate success rate has remained fairly constant over the 6 years of the study. Complications were significantly more likely to occur when dealing with femoropopliteal compared with iliac lesions. Overall, the immediate failure rate was also significantly higher in distal compared with proximal lesions (Table II). Failure was no more likely in femoropopliteal occlusions compared with stenoses.
10 5 1 3 1
2 53
Occlusion
A total of 14 patients developed either thrombosis at the site of the angioplasty (four) or distal embolisation (ten). Of these, eight patients were treated with low-dose IAT, five successfully. The three patients in whom IAT failed and three others underwent an operation (five local or distant embolectomy and one femoropopliteal bypass). One patient was noted to have a tiny embolus in a calf vessel after a superficial femoral artery angioplasty. She was treated conservatively as all of her peripheral pulses were present, and her Doppler pressure had risen following the angioplasty. A total of 13 patients remain well and are symptomatically improved at a median follow-up of 12 months (range 4-32 months). The other patient reoccluded his superficial femoral artery 8 months later and then had a femoropopliteal bypass.
Inability to complete procedure The reasons for the procedure being abandoned before completion are shown in Table I. In all, three patients were noted to have progression of their disease since the original intravenous digital subtraction angiogram (IV DSA). These occurred early in our experience and we would now treat these with intraarterial thrombolysis (IAT) and proceed to angioplasty as appropriate (4,5). None of the patients was made worse by the failure to complete the procedure and 10 subsequently went on to have a successful angioplasty.
Bleeding from puncture site In all, nine patients developed haematomas after what was initially thought to be a successful angioplasty. Two required operation to suture the catheter entry site. One other patient, who had also had IAT, arrested and died on the way to the operating theatre. This case has been described elsewhere (4). The remaining patients were treated conservatively.
Complications In each of the patients who developed a complication the dilatation had been achieved satisfactorily.
Table II. Failure of PTA, related to site of occlusion or stenosis
(n = 226)
Iliac lesions (n = 86)
39 26 65
8 2 10
Femoropopliteal lesions Procedure not completed Complications Overall immediate failure
9 9 7 6
NS P < 0.02 P
