Catheterization and Cardiovascular Diagnosis 21:154-158 (1990)
Percutaneous Popliteal Approach for Angioplasty of Superficial Femoral Artery Occlusions Rafic Zaitoun,
MD,
Sriram S. lyer,
MD,
Ruben F. Lewin,
MD,
and Gerald Dorros, MD
Angioplasty using the percutaneous popliteal approach was utilized in 50 patients (PTS) to recanalize 59 occluded superficial femoral arteries which had been unsuccessfully canalized by using the antegrade approach because of either a flush origin occlusion or inability to maintain the guide wire in the true lumen. All PTS had claudication; 8 had rest pain; 3 had non-healing ulcers. The laser ProbeTMwas used in 17 cases and the RotablatorTMin 3 cases. Occlusion length varied between 1 and 40 cm: 7 lesions were 20 cm (group 3). An angiographic success was obtained in 48/59 lesions (61%): 14/16 (87%) in groups 1 and 2 and 34/43 (79%) in group 3. Three PTS needed complementary common femoral endarterectomy and one required percutaneous aspiration of a thromboembolus. Complications included: arterial perforation and/or dissection (without clinical sequelae) in 11 and a popliteal hematoma in 1 PT. One patient with a severely ischemic leg underwent successful emergency vascular surgery, while another limb salvage patient required belowknee amputation. There was no worsening of limb ischemia from any popliteal approach attempt. At discharge, 39 patients (78%) whose outcome would have been unsuccessful with the traditional antegrade approach were clinically improved after utilizing the popliteal approach to achieve a successful angioplasty procedure. Key words: peripheral angioplasty, peripheral vascular disease, occluded superficial femoral arteries
INTRODUCTION Conventional balloon angioplasty (PTA) is a primary treatment modality for occlusive peripheral vascular disease [ 1 1 . Other therapeutic modalities which have been evaluated include atherectomy [ 2 , 3 ] , and laser-assisted angioplasty [4].However, appropriate vascular access is often crucial to perform a successful procedure. Antegrade vascular access to recanalize the superficial femoral artery can be difficult or impossible to obtain, and, therefore, would nullify any possibility of a successful procedure. This unfortunately may be true in obese patients with a large panniculus or in patients with high origin (anatomical variation) of the superficial femoral artery or a flush occlusion of the origin of the superficial femoral artery. The contralateral femoral or brachial approach may be successfully utilized for ostial superficial femoral artery disease but still may not find the entry into the true lumen in a flush occlusion; even when the lumen is correctly entered sufficient support may not be provided to cross the occluded segment. The percutaneous popliteal technique [5,6] was utilized as an approach to enable angioplasty in patients who had a failed antegrade approach attempt and/or flush occlusion of the superficial femoral artery (Fig. 1). This manuscript describes, 0 1990 Wiley-Liss, Inc.
in detail, our current techniques, successes, and encumbrances related to this new technique. MATERIALS AND METHODS Patient Population Angioplasty was performed in 50 patients, 35 men (mean age: 66 yr) to recanalize 59 occluded superficial femoral arteries. Fifteen patients were diabetic. All patients had life-style-limiting claudication; 8 had rest pain; and 3 had non-healing ulcers. All patients had previous
From the Department of Cardiology, St. Luke's Medical Center, Milwaukee, Wisconsin. lnterventional Cardiologist, St. Luke's Medical Center, Milwaukee, WI 53215 (R.F.L., G.D.). Director, The William Dorros-lsadore Feuer Foundation For lnterventional Cardiovascular Disease, LTD., Milwaukee, WI (G.D.). Fellow, the William Dorroslsadore Feuer Foundation For lnterventional Cardiovascular Disease, Ltd., Milwaukee, WI (R.Z., S.S.I.)
Received April 25, 1990; revision accepted July 5, 1990 Address reprint requests to Gerald Dorros, M.D., 2901 W. Kinnickinnic River Parkway #512, Milwaukee, WI 53215.
Percutaneous Popliteal Approach
155
Fig. 1. A: Occluded origin of superficial femoral artery demonstrated by retrograde contrast injection into the superficial femoral artery. 6:Patent superficial femoral artery after angioplasty via the popliteal approach.
diagnostic angiography studies which showed occluded superficial femoral arteries of which three-quarters were flush-origin occlusions. The occluded vessel segment lengths varied from 1 to 40 cm (mean length: 24 cm). The failed antegrade approach attempts were a result of inability to cross the occlusion with a guide wire (0.035 in.) or maintain the guide wire in the true lumen (i.e., the guide wire repetitively perforated the vessel wall). Technique of the Popliteal Approach
Using the Seldinger technique (Fig. 2), the common femoral artery was punctured in the antegrade fashion. A 5 Fr dilator was then advanced over a guide wire and secured in place. Contrast was injected into the profunda to visualize the popliteal artery via the collateral vessels. The patient was then turned and placed in the prone position on the angiography table. The popliteal fossa was prepared and draped. The area was infiltrated with local anesthetic. Contrast, injected into the profunda arterial catheter, enabled visualization of the popliteal artery. Under fluoroscopy, the artery was entered with an 18 ga. arterial needle. An 0.035 in. soft-tipped guide wire was introduced. A 6 Fr arterial sheath with sidearm was introduced over the guide wire and, when needed, a larger sheath (up to 11 Fr in size) was utilized, Heparin
(3,000-5,000 U) was administered through the popliteal sheath. A 6 Fr Teflon multipurpose angiographic catheter was advanced over the 0.035 in. guide wire. The GlidewireTM (Terumo, Tokyo, Japan) was used exclusively in the last 35 cases as the wire to cross the occluded segment. The guide wire was advanced into the common femoral artery, often requiring the structural support of the multipurpose catheter. Occasionally, to redirect and/or maintain the guide wire’s intraluminal pathway, a 6 or 7 Fr. right Judkin’s coronary catheter was employed. After crossing the lesion with the angiographic catheter, the GlidewireTMwas removed and exchanged for a 0.035 in. Amplatz guide wire which was then advanced and positioned in the iliac artery or abdominal aorta. The occluded superficial femoral artery segment was then dilated, using a 5 Fr balloon angioplasty catheter with a 5 or 6 mm balloon, 10 cm long. Early in our series, a “hot tip” laser catheter (Laser ProbeTM,Trimedyne, Tustin, CA) was used to cross the lesion. Then, an 0.035 in. soft-tipped guide wire was advanced through the channel created and placed distal to the lesion. Standard balloon angioplasty was thenperformed as previously described. However, the GlidewireTMhas obviated the need for this hot tip laser catheter. In 3 patients, once the lesion was crossed, the 0.035 in. wire was exchanged for an 0.009 in. wire.
156
Zaitoun et al.
Fig. 2. Superficial femoral artery (SFA) angioplasty by the popliteal approach. A: Contrast injection into lefl profunda artery demonstrating occluded SFA. B-D: Collateral filling of the
popliteal artery. E: 0.035 in. guide wire and arterial sheath in the popliteal artery. F-H: Post PTA angiography showing patent popliteal, mid, and proximal SFA.
Rotational atherectomy was performed by using the RotablatorTM[3] (Heart Technology, Seattle, WA). A 9 Fr arterial sheath was utilized for burr sizes 5 3 mm. An 11 Fr sheath was required for a 3.5 mm burr. Ealloon angioplasty was not used in conjunction with rotational atherectomy. In all cases, a transocclusion pressure gradient was obtained by simultaneously recording the arterial pressures via the profunda catheter and the popliteal artery sheath. Reduction or obliteration of this
gradient provided hemodynamic proof of successful arterial recanalization. The final angiograms were obtained with contrast (Isovue, Bristol-Myers Squibb, Princeton, NJ) injection through the popliteal artery sheath or via an angiographic catheter placed in the proximal superficial femoral artery. The popliteal and femoral sheaths were sequentially removed at the end of the procedure with direct pressure applied at each site to obtain hemostasis (usually 15-20 min).
Percutaneous Popliteal Approach
157
served in 11 patients (19%). A small popliteal hematoma An angiographic success was defined as a less than occurred in 1 patient. There were no clinically significant 50% residual narrowing and with a good antegrade flow. groin hematomas, and no patient required blood transfuA clinical success (patient improvement) was defined as sions. In 2 patients with severe leg ischemia angioplasty via a return of pedal pulse as well as relief of claudication or the popliteal approach was performed in order to salvage rest pain prior to discharge. the limb. The procedures were technically successful and opened the occluded superficial femoral arteries. HowRESULTS ever, a femoropopliteal popliteal tibia1 graft was required Occluded vessel segments were classified into 3 in 1 patient to salvage the leg because of severe occlusive groups according to the length of occlusion: Group 1 tibioperoneal vessel disease. The other patient, with nonlesions were 20 cm (n = 43). sites and occluded tibioperoneal vessels, required a beAn angiographic success was achieved in 48/59 le- low-knee amputation. No worsening of limb ischemia sions (81%): Group I, 717 (100%); group 2, 7/9 (78%); could be attributed to the popliteal technique in and of and, group 3,34143 (79%). A hot tip laser was used in 17 itself. cases; 15 of these occlusions were 2 2 0 cm. The laser was successful in 12/17 (70%); balloon angioplasty was performed in all of these cases once the occluded seg- DISCUSSION ment had been crossed with the laser. All 3 rotational Angioplasty was performed by the popliteal approach atherectomy cases were angiographically and clinically in patients who had either a failed antegrade attempt or successful. Clinical improvement was achieved in 39/50 were likely to be unsuccessful because of a flush occlu(78%) patients. sion of the origin of the superficial femoral artery. Contrast injection into the profunda artery permitted Complementary Procedures via collateral flow visualization and cannulation of the In 2 patients, a hard calcified plaque was present at the popliteal artery, usually in less than 1 min in 90% of origin of the superficial femoral artery which could not patients. All arteries were cannulated in less than 2 min, be successfully dilated by balloon angioplasty , and and using less than 20 ml of contrast. Thus, this percuwhich compromised antegrade blood flow. These cases taneous popliteal approach appears to be a successful and were identified by the failure to decrease the profundasafe method for cannulization of the artery and intupopliteal arterial gradient and a satisfactory angiographic itively appears to be a better technique than blind arterial picture of the superficial femoral artery distal to its oripunctures without the presence of a palpable pulse or by gin. The patients were sent for elective endarterectomy using bone landmarks or doppler signals to locate the of the proximal superficial femoral and/or distal common popliteal artery. femoral artery. Immediately following surgery, the The GlidewireTM successfully crossed the occluded popliteal and pedal pulses became palpable. An addisuperficial femoral segments quickly, relatively easily, tional patient had a significant dissection of the origin of and obviated the need for expensive, and cumbersome, the superficial femoral which extended into the common non-steerable hot tip lasers. Laser-assisted angioplasty femoral artery and compromised antegrade flow. A was performed early in our series; laser has not been proximal superficial femoral artery-common femoral enemployed to cross an occluded vessel segment in our last darterectomy was electively performed subsequent to the 30 cases. The overall success using the laser probe was angioplasty procedure. The popliteal and pedal pulses 12/17 (70%), while that employing conventional balloon appeared following surgery. (85%) cases. The 3 cases angioplasty alone was 33/39 During 1 procedure, angiography showed slow anteperformed with the rotational atherectomy, done under grade flow and multiple intraluminal filling defects coninvestigational protocol, could have been accomplished sistent with thrombus. Percutaneous aspiration of a . with conventional balloon angioplasty thromboembolus [7] was performed and multiple speciSuccess rate (Fig. 3) improved with operator experimens were removed. The antegrade blood flow imence. Only 18 of the first 27 cases (67%) were successproved and the profunda-popliteal transocclusion gradi30 of the last 32 cases (94%) were successful, whereas ent was abolished. A popliteal pulse was present at the ful, including the 3 cases requiring elective, localized end of the procedure. endarterectomy and the 1 case necessitating percutaneComplications ous aspiration of a thromboembolus. In addition, the Angiographically apparent but clinically insignificant length of the occlusion was not an impediment to success perforations and/or arterial wall dissections were ob- (Fig. 4). Definitions
158
Zaitoun et al.
Angiographic Success
lr
have been failures utilizing traditional approaches. Interventionists should be aware of this technique, and possibly include it in their repertoire.
100% 90 % 8 0% 70% 60°h 5oQi~
18/27 (67%)
ACKNOWLEDGMENTS 30132
This work was supported by a grant from the William Dorros-Isadore Feuer Foundation for Interventional Cardiovascular Disease, Ltd., Milwaukee, WI, 53215.
1-27
Cases
Fig. 3. Angiographic success: Improved success with in' 3 cases with complementary creased operator experience ( proximal SFAtcommon femoral endarterectomyand 1 case with percutaneous aspiration of thromboembolus).
An gio gr a phic Success
100% 90% 80% 7 0 O% 60% oo/o
719 (78%)
(10 crn
Fig. 4.
10-20 cm >20 crn Lesion Length
Angiographic success related to occlusion length.
The percutaneous popliteal approach is an effective angioplasty technique to successfully recanalize occluded superficial femoral arteries that would otherwise
REFERENCES I . Becker G , Katzen B, Dake M: Non-coronary angioplasty. Radiology 170:921-940, 1989. 2. Von Polnitz A, Nerlich A , Berger H , Hofling B: Percutaneous peripheral atherectomy: angiographic and clinical follow-up of 60 patients. J Am Coll Cardiol 15:682-688, 1990. 3. Dorros G, Cooley R, lyer SS, Zaitoun R , Lewin RF, Olson K: Acute angiographic and clinical outcome of high speed percutaneous rotational atherectomy (rotablator). Am J Cardiol, publication pending. 4. Sanborn T. Cumberland D, Greenfield A, Welsh C, Guben J: Percutaneous laser thermal angioplasty: Initial results and one year follow-up in 129 femoral popliteal lesions. Radiology 168:121125, 1988. 5 . Toonesen 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 Radio1 11:127-131, 1988. 6. Leachman DR. Avedissian N, Krajcer Z, Angelini P: Transluminal laser angioplasty of the femoral popliteal circulation by use of percutaneous popliteal approach. Am J Cardiol 64:106-108. 1989. 7. Dorros G, Jamnadas P, Lewin RF. Sachdev N: Percutaneous aspiration of a thromboembolus. Cathet Cardiovasc Diagn 17:202206. 1989.
Percutaneous Popliteal Approach for Angioplasty of Superficial Femoral Artery Occlusions Rafic Zaitoun,
MD,
Sriram S. lyer,
MD,
Ruben F. Lewin,
MD,
and Gerald Dorros, MD
Angioplasty using the percutaneous popliteal approach was utilized in 50 patients (PTS) to recanalize 59 occluded superficial femoral arteries which had been unsuccessfully canalized by using the antegrade approach because of either a flush origin occlusion or inability to maintain the guide wire in the true lumen. All PTS had claudication; 8 had rest pain; 3 had non-healing ulcers. The laser ProbeTMwas used in 17 cases and the RotablatorTMin 3 cases. Occlusion length varied between 1 and 40 cm: 7 lesions were 20 cm (group 3). An angiographic success was obtained in 48/59 lesions (61%): 14/16 (87%) in groups 1 and 2 and 34/43 (79%) in group 3. Three PTS needed complementary common femoral endarterectomy and one required percutaneous aspiration of a thromboembolus. Complications included: arterial perforation and/or dissection (without clinical sequelae) in 11 and a popliteal hematoma in 1 PT. One patient with a severely ischemic leg underwent successful emergency vascular surgery, while another limb salvage patient required belowknee amputation. There was no worsening of limb ischemia from any popliteal approach attempt. At discharge, 39 patients (78%) whose outcome would have been unsuccessful with the traditional antegrade approach were clinically improved after utilizing the popliteal approach to achieve a successful angioplasty procedure. Key words: peripheral angioplasty, peripheral vascular disease, occluded superficial femoral arteries
INTRODUCTION Conventional balloon angioplasty (PTA) is a primary treatment modality for occlusive peripheral vascular disease [ 1 1 . Other therapeutic modalities which have been evaluated include atherectomy [ 2 , 3 ] , and laser-assisted angioplasty [4].However, appropriate vascular access is often crucial to perform a successful procedure. Antegrade vascular access to recanalize the superficial femoral artery can be difficult or impossible to obtain, and, therefore, would nullify any possibility of a successful procedure. This unfortunately may be true in obese patients with a large panniculus or in patients with high origin (anatomical variation) of the superficial femoral artery or a flush occlusion of the origin of the superficial femoral artery. The contralateral femoral or brachial approach may be successfully utilized for ostial superficial femoral artery disease but still may not find the entry into the true lumen in a flush occlusion; even when the lumen is correctly entered sufficient support may not be provided to cross the occluded segment. The percutaneous popliteal technique [5,6] was utilized as an approach to enable angioplasty in patients who had a failed antegrade approach attempt and/or flush occlusion of the superficial femoral artery (Fig. 1). This manuscript describes, 0 1990 Wiley-Liss, Inc.
in detail, our current techniques, successes, and encumbrances related to this new technique. MATERIALS AND METHODS Patient Population Angioplasty was performed in 50 patients, 35 men (mean age: 66 yr) to recanalize 59 occluded superficial femoral arteries. Fifteen patients were diabetic. All patients had life-style-limiting claudication; 8 had rest pain; and 3 had non-healing ulcers. All patients had previous
From the Department of Cardiology, St. Luke's Medical Center, Milwaukee, Wisconsin. lnterventional Cardiologist, St. Luke's Medical Center, Milwaukee, WI 53215 (R.F.L., G.D.). Director, The William Dorros-lsadore Feuer Foundation For lnterventional Cardiovascular Disease, LTD., Milwaukee, WI (G.D.). Fellow, the William Dorroslsadore Feuer Foundation For lnterventional Cardiovascular Disease, Ltd., Milwaukee, WI (R.Z., S.S.I.)
Received April 25, 1990; revision accepted July 5, 1990 Address reprint requests to Gerald Dorros, M.D., 2901 W. Kinnickinnic River Parkway #512, Milwaukee, WI 53215.
Percutaneous Popliteal Approach
155
Fig. 1. A: Occluded origin of superficial femoral artery demonstrated by retrograde contrast injection into the superficial femoral artery. 6:Patent superficial femoral artery after angioplasty via the popliteal approach.
diagnostic angiography studies which showed occluded superficial femoral arteries of which three-quarters were flush-origin occlusions. The occluded vessel segment lengths varied from 1 to 40 cm (mean length: 24 cm). The failed antegrade approach attempts were a result of inability to cross the occlusion with a guide wire (0.035 in.) or maintain the guide wire in the true lumen (i.e., the guide wire repetitively perforated the vessel wall). Technique of the Popliteal Approach
Using the Seldinger technique (Fig. 2), the common femoral artery was punctured in the antegrade fashion. A 5 Fr dilator was then advanced over a guide wire and secured in place. Contrast was injected into the profunda to visualize the popliteal artery via the collateral vessels. The patient was then turned and placed in the prone position on the angiography table. The popliteal fossa was prepared and draped. The area was infiltrated with local anesthetic. Contrast, injected into the profunda arterial catheter, enabled visualization of the popliteal artery. Under fluoroscopy, the artery was entered with an 18 ga. arterial needle. An 0.035 in. soft-tipped guide wire was introduced. A 6 Fr arterial sheath with sidearm was introduced over the guide wire and, when needed, a larger sheath (up to 11 Fr in size) was utilized, Heparin
(3,000-5,000 U) was administered through the popliteal sheath. A 6 Fr Teflon multipurpose angiographic catheter was advanced over the 0.035 in. guide wire. The GlidewireTM (Terumo, Tokyo, Japan) was used exclusively in the last 35 cases as the wire to cross the occluded segment. The guide wire was advanced into the common femoral artery, often requiring the structural support of the multipurpose catheter. Occasionally, to redirect and/or maintain the guide wire’s intraluminal pathway, a 6 or 7 Fr. right Judkin’s coronary catheter was employed. After crossing the lesion with the angiographic catheter, the GlidewireTMwas removed and exchanged for a 0.035 in. Amplatz guide wire which was then advanced and positioned in the iliac artery or abdominal aorta. The occluded superficial femoral artery segment was then dilated, using a 5 Fr balloon angioplasty catheter with a 5 or 6 mm balloon, 10 cm long. Early in our series, a “hot tip” laser catheter (Laser ProbeTM,Trimedyne, Tustin, CA) was used to cross the lesion. Then, an 0.035 in. soft-tipped guide wire was advanced through the channel created and placed distal to the lesion. Standard balloon angioplasty was thenperformed as previously described. However, the GlidewireTMhas obviated the need for this hot tip laser catheter. In 3 patients, once the lesion was crossed, the 0.035 in. wire was exchanged for an 0.009 in. wire.
156
Zaitoun et al.
Fig. 2. Superficial femoral artery (SFA) angioplasty by the popliteal approach. A: Contrast injection into lefl profunda artery demonstrating occluded SFA. B-D: Collateral filling of the
popliteal artery. E: 0.035 in. guide wire and arterial sheath in the popliteal artery. F-H: Post PTA angiography showing patent popliteal, mid, and proximal SFA.
Rotational atherectomy was performed by using the RotablatorTM[3] (Heart Technology, Seattle, WA). A 9 Fr arterial sheath was utilized for burr sizes 5 3 mm. An 11 Fr sheath was required for a 3.5 mm burr. Ealloon angioplasty was not used in conjunction with rotational atherectomy. In all cases, a transocclusion pressure gradient was obtained by simultaneously recording the arterial pressures via the profunda catheter and the popliteal artery sheath. Reduction or obliteration of this
gradient provided hemodynamic proof of successful arterial recanalization. The final angiograms were obtained with contrast (Isovue, Bristol-Myers Squibb, Princeton, NJ) injection through the popliteal artery sheath or via an angiographic catheter placed in the proximal superficial femoral artery. The popliteal and femoral sheaths were sequentially removed at the end of the procedure with direct pressure applied at each site to obtain hemostasis (usually 15-20 min).
Percutaneous Popliteal Approach
157
served in 11 patients (19%). A small popliteal hematoma An angiographic success was defined as a less than occurred in 1 patient. There were no clinically significant 50% residual narrowing and with a good antegrade flow. groin hematomas, and no patient required blood transfuA clinical success (patient improvement) was defined as sions. In 2 patients with severe leg ischemia angioplasty via a return of pedal pulse as well as relief of claudication or the popliteal approach was performed in order to salvage rest pain prior to discharge. the limb. The procedures were technically successful and opened the occluded superficial femoral arteries. HowRESULTS ever, a femoropopliteal popliteal tibia1 graft was required Occluded vessel segments were classified into 3 in 1 patient to salvage the leg because of severe occlusive groups according to the length of occlusion: Group 1 tibioperoneal vessel disease. The other patient, with nonlesions were 20 cm (n = 43). sites and occluded tibioperoneal vessels, required a beAn angiographic success was achieved in 48/59 le- low-knee amputation. No worsening of limb ischemia sions (81%): Group I, 717 (100%); group 2, 7/9 (78%); could be attributed to the popliteal technique in and of and, group 3,34143 (79%). A hot tip laser was used in 17 itself. cases; 15 of these occlusions were 2 2 0 cm. The laser was successful in 12/17 (70%); balloon angioplasty was performed in all of these cases once the occluded seg- DISCUSSION ment had been crossed with the laser. All 3 rotational Angioplasty was performed by the popliteal approach atherectomy cases were angiographically and clinically in patients who had either a failed antegrade attempt or successful. Clinical improvement was achieved in 39/50 were likely to be unsuccessful because of a flush occlu(78%) patients. sion of the origin of the superficial femoral artery. Contrast injection into the profunda artery permitted Complementary Procedures via collateral flow visualization and cannulation of the In 2 patients, a hard calcified plaque was present at the popliteal artery, usually in less than 1 min in 90% of origin of the superficial femoral artery which could not patients. All arteries were cannulated in less than 2 min, be successfully dilated by balloon angioplasty , and and using less than 20 ml of contrast. Thus, this percuwhich compromised antegrade blood flow. These cases taneous popliteal approach appears to be a successful and were identified by the failure to decrease the profundasafe method for cannulization of the artery and intupopliteal arterial gradient and a satisfactory angiographic itively appears to be a better technique than blind arterial picture of the superficial femoral artery distal to its oripunctures without the presence of a palpable pulse or by gin. The patients were sent for elective endarterectomy using bone landmarks or doppler signals to locate the of the proximal superficial femoral and/or distal common popliteal artery. femoral artery. Immediately following surgery, the The GlidewireTM successfully crossed the occluded popliteal and pedal pulses became palpable. An addisuperficial femoral segments quickly, relatively easily, tional patient had a significant dissection of the origin of and obviated the need for expensive, and cumbersome, the superficial femoral which extended into the common non-steerable hot tip lasers. Laser-assisted angioplasty femoral artery and compromised antegrade flow. A was performed early in our series; laser has not been proximal superficial femoral artery-common femoral enemployed to cross an occluded vessel segment in our last darterectomy was electively performed subsequent to the 30 cases. The overall success using the laser probe was angioplasty procedure. The popliteal and pedal pulses 12/17 (70%), while that employing conventional balloon appeared following surgery. (85%) cases. The 3 cases angioplasty alone was 33/39 During 1 procedure, angiography showed slow anteperformed with the rotational atherectomy, done under grade flow and multiple intraluminal filling defects coninvestigational protocol, could have been accomplished sistent with thrombus. Percutaneous aspiration of a . with conventional balloon angioplasty thromboembolus [7] was performed and multiple speciSuccess rate (Fig. 3) improved with operator experimens were removed. The antegrade blood flow imence. Only 18 of the first 27 cases (67%) were successproved and the profunda-popliteal transocclusion gradi30 of the last 32 cases (94%) were successful, whereas ent was abolished. A popliteal pulse was present at the ful, including the 3 cases requiring elective, localized end of the procedure. endarterectomy and the 1 case necessitating percutaneComplications ous aspiration of a thromboembolus. In addition, the Angiographically apparent but clinically insignificant length of the occlusion was not an impediment to success perforations and/or arterial wall dissections were ob- (Fig. 4). Definitions
158
Zaitoun et al.
Angiographic Success
lr
have been failures utilizing traditional approaches. Interventionists should be aware of this technique, and possibly include it in their repertoire.
100% 90 % 8 0% 70% 60°h 5oQi~
18/27 (67%)
ACKNOWLEDGMENTS 30132
This work was supported by a grant from the William Dorros-Isadore Feuer Foundation for Interventional Cardiovascular Disease, Ltd., Milwaukee, WI, 53215.
1-27
Cases
Fig. 3. Angiographic success: Improved success with in' 3 cases with complementary creased operator experience ( proximal SFAtcommon femoral endarterectomyand 1 case with percutaneous aspiration of thromboembolus).
An gio gr a phic Success
100% 90% 80% 7 0 O% 60% oo/o
719 (78%)
(10 crn
Fig. 4.
10-20 cm >20 crn Lesion Length
Angiographic success related to occlusion length.
The percutaneous popliteal approach is an effective angioplasty technique to successfully recanalize occluded superficial femoral arteries that would otherwise
REFERENCES I . Becker G , Katzen B, Dake M: Non-coronary angioplasty. Radiology 170:921-940, 1989. 2. Von Polnitz A, Nerlich A , Berger H , Hofling B: Percutaneous peripheral atherectomy: angiographic and clinical follow-up of 60 patients. J Am Coll Cardiol 15:682-688, 1990. 3. Dorros G, Cooley R, lyer SS, Zaitoun R , Lewin RF, Olson K: Acute angiographic and clinical outcome of high speed percutaneous rotational atherectomy (rotablator). Am J Cardiol, publication pending. 4. Sanborn T. Cumberland D, Greenfield A, Welsh C, Guben J: Percutaneous laser thermal angioplasty: Initial results and one year follow-up in 129 femoral popliteal lesions. Radiology 168:121125, 1988. 5 . Toonesen 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 Radio1 11:127-131, 1988. 6. Leachman DR. Avedissian N, Krajcer Z, Angelini P: Transluminal laser angioplasty of the femoral popliteal circulation by use of percutaneous popliteal approach. Am J Cardiol 64:106-108. 1989. 7. Dorros G, Jamnadas P, Lewin RF. Sachdev N: Percutaneous aspiration of a thromboembolus. Cathet Cardiovasc Diagn 17:202206. 1989.
