Lower Limb Artery Interventions

Lower limb artery interventions encompass the interventional treatment of peripheral artery diseases (PAD) which includes plain old balloon angioplasty (POBA), angioplasty and stenting, and atherectomy and drug-coated balloon (DCB) angioplasty.

Plain old balloon angioplasty (POBA), also known as percutaneous transluminal angioplasty (PTA), is an interventional procedure employed to treat narrowed or blocked blood vessels, particularly arteries, through the use of a specialized balloon catheter. During POBA, a catheter with an inflatable balloon at its tip is percutaneously introduced into the affected blood vessel, guided by fluoroscopy and DSA. The catheter is advanced until the balloon reaches the narrowed or occluded segment of the vessel.

Once positioned, the balloon is inflated, exerting pressure against the vessel walls. This inflation compresses the atherosclerotic plaque or other obstructive material, widening the lumen of the blood vessel and restoring adequate blood flow. After a short period of inflation, the balloon is deflated and withdrawn, allowing for resumed blood flow through the dilated artery.

These procedures aim to improve blood flow, alleviate claudication (leg pain with walking), improve wound healing, and prevent limb loss in patients with severe peripheral artery disease (PAD). While POBA is effective in many cases, it carries the risk of complications such as dissection (tearing of the vessel wall), vessel rupture, or restenosis (re-narrowing of the treated artery). In some instances, adjunctive techniques such as stent placement or atherectomy may be utilized during the procedure to optimize outcomes and reduce the likelihood of restenosis.

Peripheral artery angioplasty and stenting aim at addressing arterial stenosis or occlusion in the lower extremities. The procedure involves the percutaneous insertion of a catheter into the affected lower leg artery, under fluoroscopic guidance. The catheter is carefully maneuvered to the narrowed or blocked segment of the artery. Once positioned, a specialized balloon at the catheter tip is inflated. The inflation of the balloon applies pressure against the vessel walls, mechanically compressing the atherosclerotic plaque or other obstructive material. This dilation of the arterial lumen restores blood flow and improves perfusion to the lower leg.

In cases where the vessel remains at risk of re-narrowing or closure, a stent may be deployed. A stent is a mesh-like metallic device that is placed within the dilated segment of the artery to provide structural support and prevent recoil or restenosis. The stent is precisely positioned and expanded, ensuring that the artery remains open and unobstructed, facilitating optimal blood flow.

As with any interventional procedure, there are potential risks and complications, including dissection, thrombosis (blood clot formation), embolization (clot or plaque debris traveling downstream), or stent fracture.

Peripheral artery atherectomy, combined with drug-coated balloon angioplasty, represents a comprehensive interventional approach to address atherosclerotic lesions within the arteries of the lower extremities.

Atherectomy refers to the mechanical removal of atherosclerotic plaque from the arterial walls. In the context of lower leg arteries, this technique involves the percutaneous insertion of a specialized catheter into the affected artery. The catheter incorporates cutting blades, rotational burrs, or laser energy to meticulously debulk or vaporize the plaque, restoring luminal patency and improving blood flow.

In conjunction with atherectomy, drug-coated balloon angioplasty is employed to optimize the results of the intervention. This technique involves the use of a balloon catheter coated with an anti-restenotic medication, typically an anti-proliferative drug. Upon inflation, the drug coating is released, providing local delivery of the medication to the treated arterial segment. This drug helps inhibit smooth muscle cell proliferation and reduces the risk of restenosis, thereby improving long-term outcomes.

The combined approach of lower leg artery atherectomy and drug-coated balloon angioplasty aims to achieve effective plaque removal while also providing sustained drug delivery (of paclitaxel) to prevent restenosis. By addressing both the mechanical obstruction caused by the plaque and the subsequent cellular responses leading to restenosis (neo-intimal hyperplasia), this approach offers a comprehensive solution to lower leg arterial disease.

A&I Protocol

"Up and over" technique:

Seldinger technique is used to access the ipsilateral (opposite site of affected limb) common femoral artery using ultrasound guidance.
An 0.035" Bentson (work horse) wire and flush catheter are directed towards the abdominal aorta at the vertebral level of L1/2. An aortogram is performed using the contrast injector (10 mls at 10 ml/sec) or manual hand contrast injection to demonstrate the abdominal aorta, aortic bifurcation, bilateral renal arteries (stenosis or FMD?), and bilateral iliac arteries.
This DSA run is used as a roadmap to navigate to the contralateral side. Once the contralateral iliac arteries are access, the short sheath is exchanged to a longer 6F or 7F sheath (depending on the intervention planned).
Additional angiograms are performed of the affect lower limb with contrast injector runs (5 mls at 5 ml/sec), from the contralateral common femoral artery to the distal foot arteries.
Special attention to the superficial femoral artery, popliteal artery, anterior tibial artery, tibio-peroneal trunk (TPT), peroneal artery, and posterior tibial artery.
Once the stenosed or blocked vessel or vessels have been identified, a wire and Bern-shaped catheter are used to navigate past the stenosis or blockage.
For the arteries below the knee, the wire and catheter systems are recommended to be exchanged to a 0.018" or 0.014" system.
Vessel diameters can be measured on the angiography system, and appropriate angioplasty balloons can be inflated in the affected area.
Treatment can stop at angioplasty or can progress to further intervention with either 1. Stenting or 2. Atherectomy and DCB angioplasty.

Stenting involves the measurement of the vessel diameter and deploying the stent at the site of stenosis. Stents can be covered or uncovered. Stents can also be self-expanding or balloon-expandable stents. For long lesions, >1 stent may be used and stent overlap is advised.
Atherectomy involves the insertion of a filter device, distal to the lesion. A suitably sized atherectomy device is selected and is used to "cut" away atherosclerotic plaque on the medial and lateral aspect of an anterior-posterior angiography image. Then the process is repeated on the orthogonal view (either LAO45 or RAO45) to provide a circumferential "cutting" of the plaque.

Following the completion of angioplasty on its own, or in combination with 1. stenting or 2. atherectomy and DCB angioplasty, the devices are removed and a vascular closure device is inserted in the common femoral artery puncture site.

"Downhill" technique:

Seldinger technique is used to gain access into the common femoral artery (CFA) on the same affected side of the patient. Similar DSA imaging techniques are performed for the lower limb and treatment pathways and devices used. Contrast injector is usually not required, as manual hand contrast media injections suffice.

DSA of the right superficial femoral artery (SFA) pre-intervention.

Fluoroscopy (LIH) of the superficial femoral artery undergoing directional atherectomy.

DSA of the superficial femoral artery post-atherectomy and drug-coated balloon angioplasty.

References

Tepe G, Laird J, Schneider P, Brodmann M, Krishnan P, Micari A, et al. Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial. Circulation. 2015 Feb 3;131(5):495–502.
Pourmoussa AJ, Smuclovisky E, Peña C, Katzen B. Maximizing Angioplasty Results in Peripheral Interventions. Tech Vasc Interv Radiol. 2022 Sep;25(3):100839.
Kayssi A, Al-Atassi T, Oreopoulos G, Roche-Nagle G, Tan KT, Rajan DK. Drug-eluting balloon angioplasty versus uncoated balloon angioplasty for peripheral arterial disease of the lower limbs. Cochrane Database Syst Rev. 2016 Aug 4;2016(8):CD011319.
Barbarawi M, Qazi AH, Lee J, Barbarawi O, Al-Abdouh A, Mhanna M, et al. Meta-Analysis Comparing Drug-Coated Balloons and Percutaneous Transluminal Angioplasty for Infrapopliteal Artery Disease. Am J Cardiol. 2022 Nov 15;183:115–21.
Faglia E, Favales F, Quarantiello A, Calia P, Brambilla G, Rampoldi A, et al. Feasibility and effectiveness of peripheral percutaneous transluminal balloon angioplasty in diabetic subjects with foot ulcers. Diabetes Care. 1996 Nov;19(11):1261–4.