Leading articles Br. J. Surg. 1992, Vol. 79, November, 1125-1126
lntraoperative balloon angioplasty Percutaneous balloon angioplasty (PTA ) was first described in the management of peripheral vascular disease by Dotter and Judkins’ in 1964. The technique relies on the principle of using an intraluminal balloon to dilate an arterial stenosis or occlusion to such an extent that the arterial intima, media and any associated plaque split, in effect producing a new ‘lumen’. Although this was crude in approach, early patency rates after treatment of short occlusions or stenoses compare favourably with those after surgical bypass in the iliac and femoral arteries. PTA may be particularly valuable in elderly patients who are not fit for aortoiliac surgery but require an improvement in inflow before femoropopliteal or distal bypass for limb salvage. Despite reported high rates of early technical success, there is a shortage of published controlled studies regarding the mediuh- and long-term clinical efficacy of PTA. Although most workers carry out PTA in the radiological suite, an increasing number of surgeons now perform balloon angioplasty in the operating theatre, either as a primary procedure or as an adjunct to open vascular surgery. A recent sample of 100 members of the Vascular Surgical Society of Great Britain and Ireland revealed that 40 per cent performed some intraoperative angioplasty, a trend that may provoke a number of interesting controversies. The primary question that must be addressed remains: ‘Is there a genuine need for intraoperative balloon angioplasty ?’ Clearly, the role of such angioplasty will be principally as an adjunct to reconstructive vascular surgery’. However, there are probably only three situations where there is a good indication for balloon angioplasty within the operating theatre. The first is the unexpected finding of inadequate arterial inflow to the groin when attempting a planned femorofemoral, femoropopliteal or femorodistal bypass. This should be a rare event if the patient has been properly investigated, with direct aortoiliac pressure measurements when necessary, using the papaverine technique in uncertain cases3. When there is doubt regarding inflow, angioplasty should be performed in the radiology suite with PTA if indicated; by doing this not only can the success or otherwise of the proximal angioplasty be properly assessed but the need for further distal reconstruction may be avoided. The possibilities of increased risk of wound infection and slightly increased difficulty of groin dissection surrounding surgery soon after PTA may be overcome either by performing reconstructive surgery immediately after angioplasty or by deferring it for about 3 weeks where possible. It is doubtful whether it is desirable to place the viability of a distal graft at the mercy of the inevitably uncertain outcome of balloon angioplasty combined with open operation. Nevertheless, it is clear that occasionally, particularly at urgent reconstructive surgery, a situation may arise when intraoperative dilatation makes sense. The second situation where adjunctive balloon angioplasty might be seriously considered is the concomitant performance of superficial femoral or popliteal dilatation after aortoiliac bypass or similar inflow procedure; this might be done to improve run-off and so maximize the benefit of such a procedure4. While it is possible to defer angioplasty, there are technical difficulties and theoretical objections to passing an angioplasty catheter through a recently dissected groin. However, a number of workers have recently described a popliteal approach to such lesions that obviates the need for groin puncture. Also, it may occasionally be possible to insert the lower end of an aortofemoral or axillofemoral bypass or the donor end anastomosis of a femorofemoral crossover graft into the distal external iliac artery; this also facilitates later PTA by removing the need for puncture of a dissected groin. A possible third situation lies in the operative management of acute arterial thrombosis; arterial dilatation may be undertaken after catheter extraction of thrombus5.Nevertheless, with increasing acceptance and availability of percutaneous intra-arterial thrombolysis, there is less reason today for immediate operative intervention in such cases than previously. Acute thrombosis is probably best managed by lysis and subsequent PTA of appropriate causative lesions. There are some valid reasons why vascular surgeons should not universally attempt intraoperative balloon angioplasty. The most compelling of these is lack of adequate training. Insufficientangiology staff and inadequate facilities may also cause problems. It has been suggested that a minimum training period of 1 year is required to become proficient at the procedure. Unlike cardiologists, few vascular surgeons have either adequate training or an elective radiological list for angioplasty. Consequently their
OOO7-1323/92/111125-02
0 1992 Butterworth-Heinemann
Ltd
1125
Leading articles
experience must be limited to those occasions when they attempt balloon angioplasty during open operation. Clearly, techniques such as postangioplasty intraluminal stenting are outside most surgeons' training. In North America, surgeons have rightly been quick to criticize cardiologists for performing percutaneous transluminal peripheral angioplasty. Should we not therefore be equally critical when examining our own practice? If there are no experienced surgical personnel, why not invite the vascular radiologist into the operating theatre6 to perform adjunctive angioplasty ? Lack of on-call vascular radiologists may be a problem for some, but this ought not to be so in regional centres offering vascular surgery. Good cooperation between surgeon and radiologist can only benefit the patient'. As vascular'surgeons make a plea for increasing specialization and regional centres of excellence, it is vital that we either train ourselves and our proteges in the techniques of balloon angioplasty or ensure the availability of adequate experienced radiology cover.
P. T. McCollum J. W. Shaw* P. Hickman Departments of Surgery and *Radiology Ninewells Hospital Dundee DD1 9SY UK 1.
2.
3.
4.
1126
Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction: description of a new technique and a preliminary report of its application. Circulation 1964; 30: 654-70. Rutherford RB, Platt 4, Kumpe DA. The current role of percutaneous transluminal angioplasty. In: Greenhalgh RM, Jamieson CW, Nicolaides AN, eds. Vascular Surgery: Issues in Current Practice. London: Grune and Stratton, 1986: 224-44. Macpherson DS, Evans DH, Bell PRF. Common femoral artery Doppler waveforms: a comparison of three methods of objective analysis with direct pressure measurements. Br J Surg 1984; 71: 46-9. McMillan PJ, Collin J, Fletcher EWL.
5.
6.
7.
Intraoperative balloon angioplasty dilation permits simpler safer reconstructive surgery. Clin Radiol 1988; 39: 91-3. Ammar AD, Hutchinson SA. Management of acute infrainguinal arterial thrombosis. Combined intraoperative balloon thrombectomy with balloon angioplasty: a preliminary report. Surgery 1987; 101: 176-80. Motarheme A, Keifer JW, Zuska AJ. Percutaneous transluminal angioplasty as a complement to surgery. Diayn Radiol 1981; 141: 341-5. Griffith CDM, Harrison JD, Gregson RHS, Makin GS, Hopkinson BR. Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia. J R Coll Surg Edinb 1989; 34: 253-5.
Br. J. Surg., Vol. 79, No. 11. November 1992
lntraoperative balloon angioplasty Percutaneous balloon angioplasty (PTA ) was first described in the management of peripheral vascular disease by Dotter and Judkins’ in 1964. The technique relies on the principle of using an intraluminal balloon to dilate an arterial stenosis or occlusion to such an extent that the arterial intima, media and any associated plaque split, in effect producing a new ‘lumen’. Although this was crude in approach, early patency rates after treatment of short occlusions or stenoses compare favourably with those after surgical bypass in the iliac and femoral arteries. PTA may be particularly valuable in elderly patients who are not fit for aortoiliac surgery but require an improvement in inflow before femoropopliteal or distal bypass for limb salvage. Despite reported high rates of early technical success, there is a shortage of published controlled studies regarding the mediuh- and long-term clinical efficacy of PTA. Although most workers carry out PTA in the radiological suite, an increasing number of surgeons now perform balloon angioplasty in the operating theatre, either as a primary procedure or as an adjunct to open vascular surgery. A recent sample of 100 members of the Vascular Surgical Society of Great Britain and Ireland revealed that 40 per cent performed some intraoperative angioplasty, a trend that may provoke a number of interesting controversies. The primary question that must be addressed remains: ‘Is there a genuine need for intraoperative balloon angioplasty ?’ Clearly, the role of such angioplasty will be principally as an adjunct to reconstructive vascular surgery’. However, there are probably only three situations where there is a good indication for balloon angioplasty within the operating theatre. The first is the unexpected finding of inadequate arterial inflow to the groin when attempting a planned femorofemoral, femoropopliteal or femorodistal bypass. This should be a rare event if the patient has been properly investigated, with direct aortoiliac pressure measurements when necessary, using the papaverine technique in uncertain cases3. When there is doubt regarding inflow, angioplasty should be performed in the radiology suite with PTA if indicated; by doing this not only can the success or otherwise of the proximal angioplasty be properly assessed but the need for further distal reconstruction may be avoided. The possibilities of increased risk of wound infection and slightly increased difficulty of groin dissection surrounding surgery soon after PTA may be overcome either by performing reconstructive surgery immediately after angioplasty or by deferring it for about 3 weeks where possible. It is doubtful whether it is desirable to place the viability of a distal graft at the mercy of the inevitably uncertain outcome of balloon angioplasty combined with open operation. Nevertheless, it is clear that occasionally, particularly at urgent reconstructive surgery, a situation may arise when intraoperative dilatation makes sense. The second situation where adjunctive balloon angioplasty might be seriously considered is the concomitant performance of superficial femoral or popliteal dilatation after aortoiliac bypass or similar inflow procedure; this might be done to improve run-off and so maximize the benefit of such a procedure4. While it is possible to defer angioplasty, there are technical difficulties and theoretical objections to passing an angioplasty catheter through a recently dissected groin. However, a number of workers have recently described a popliteal approach to such lesions that obviates the need for groin puncture. Also, it may occasionally be possible to insert the lower end of an aortofemoral or axillofemoral bypass or the donor end anastomosis of a femorofemoral crossover graft into the distal external iliac artery; this also facilitates later PTA by removing the need for puncture of a dissected groin. A possible third situation lies in the operative management of acute arterial thrombosis; arterial dilatation may be undertaken after catheter extraction of thrombus5.Nevertheless, with increasing acceptance and availability of percutaneous intra-arterial thrombolysis, there is less reason today for immediate operative intervention in such cases than previously. Acute thrombosis is probably best managed by lysis and subsequent PTA of appropriate causative lesions. There are some valid reasons why vascular surgeons should not universally attempt intraoperative balloon angioplasty. The most compelling of these is lack of adequate training. Insufficientangiology staff and inadequate facilities may also cause problems. It has been suggested that a minimum training period of 1 year is required to become proficient at the procedure. Unlike cardiologists, few vascular surgeons have either adequate training or an elective radiological list for angioplasty. Consequently their
OOO7-1323/92/111125-02
0 1992 Butterworth-Heinemann
Ltd
1125
Leading articles
experience must be limited to those occasions when they attempt balloon angioplasty during open operation. Clearly, techniques such as postangioplasty intraluminal stenting are outside most surgeons' training. In North America, surgeons have rightly been quick to criticize cardiologists for performing percutaneous transluminal peripheral angioplasty. Should we not therefore be equally critical when examining our own practice? If there are no experienced surgical personnel, why not invite the vascular radiologist into the operating theatre6 to perform adjunctive angioplasty ? Lack of on-call vascular radiologists may be a problem for some, but this ought not to be so in regional centres offering vascular surgery. Good cooperation between surgeon and radiologist can only benefit the patient'. As vascular'surgeons make a plea for increasing specialization and regional centres of excellence, it is vital that we either train ourselves and our proteges in the techniques of balloon angioplasty or ensure the availability of adequate experienced radiology cover.
P. T. McCollum J. W. Shaw* P. Hickman Departments of Surgery and *Radiology Ninewells Hospital Dundee DD1 9SY UK 1.
2.
3.
4.
1126
Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction: description of a new technique and a preliminary report of its application. Circulation 1964; 30: 654-70. Rutherford RB, Platt 4, Kumpe DA. The current role of percutaneous transluminal angioplasty. In: Greenhalgh RM, Jamieson CW, Nicolaides AN, eds. Vascular Surgery: Issues in Current Practice. London: Grune and Stratton, 1986: 224-44. Macpherson DS, Evans DH, Bell PRF. Common femoral artery Doppler waveforms: a comparison of three methods of objective analysis with direct pressure measurements. Br J Surg 1984; 71: 46-9. McMillan PJ, Collin J, Fletcher EWL.
5.
6.
7.
Intraoperative balloon angioplasty dilation permits simpler safer reconstructive surgery. Clin Radiol 1988; 39: 91-3. Ammar AD, Hutchinson SA. Management of acute infrainguinal arterial thrombosis. Combined intraoperative balloon thrombectomy with balloon angioplasty: a preliminary report. Surgery 1987; 101: 176-80. Motarheme A, Keifer JW, Zuska AJ. Percutaneous transluminal angioplasty as a complement to surgery. Diayn Radiol 1981; 141: 341-5. Griffith CDM, Harrison JD, Gregson RHS, Makin GS, Hopkinson BR. Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia. J R Coll Surg Edinb 1989; 34: 253-5.
Br. J. Surg., Vol. 79, No. 11. November 1992
