Long-term hemodynamic evaluation of lower extremity percutaneous transluminal angioplasty

Abstract

Percutaneous transluminal angioplasty (PTA) has provided an alternative method of treatment for occlusive disease of the lower extremities. However, the long-term durability of PTA compared with that of surgical reconstruction has not been adequately evaluated. This study was undertaken to assess the long-term hemodynamic results of PTA. Thirty-four dilatations performed on 28 patients over a 30-month period and followed for 1 to 53 months were reviewed. Twenty-two dilatations were done in the iliac arteries, seven in the superficial femoral, three in the popliteal, one in the peroneal artery, and one at a bypass graft anastomosis. All patients underwent noninvasive measurements of lower extremity segmental pressure prior to dilatation and at scheduled follow-up intervals. Success was defined as an increase in the Doppler-derived segmental lower extremity/brachial index of greater than or equal to 0.15 or normalization of the index (greater than or equal to 0.90), measured at the closest level distal to the site of dilatation. Sixteen of 22 iliac dilatations (72.7%) were initially successful. However, long-term success was maintained in only six (27.6%). Cumulative hemodynamic success for the initially successful iliac dilatations was 28% at 3 years. Seven of 11 (63.6%) dilatations performed on infrainguinal arteries were initially successful; however, only two (18.2%) experienced continued success. Cumulative hemodynamic success for the initially successful infrainguinal dilatations in this group was 35% at 3 years. Although immediate patency and improvement in hemodynamic parameters are similar to comparable surgical procedures, these results demonstrate that PTA is not as durable as conventional surgical procedures.

The Effect of Lower Limb Revascularization on Flow, Perfusion, and Systemic Endothelial Function: A Systematic Review

“…The limited available evidence suggests that deterioration in flow parameters such as ABPI is common even in claudicants, with an average time to deterioration of approximately 14 months after revascularization. 23,24 Although one study assessed the correlation between flow and perfusion, 13 none of the studies directly assessed the association between flow or perfusion with systemic endothelial dysfunction. Pawlaczyk et al and Husmann and colleagues did demonstrate improvements in flow and FMD but did not assess the correlation between them.…”

“…Importantly, as observed in a number of studies in this review, improvements in perfusion may take weeks to become apparent. 23 Studies measuring systemic endothelial dysfunction using FMD were typically performed at least 4 weeks following revascularization. When considering systemic endothelial dysfunction following bypass surgery, measurements in the first few weeks may also be confounded by inflammation related to the operation.…”

“…Borozan et al 23 observed a 72% initial ABPI improvement in 34% of patients with IC treated with PTA, followed by a significant deterioration of flow during the follow-up period. Continued hemodynamic success was maintained in 37%, and overall long-term success was 27% during a mean follow-up of 16 months.…”

“…A randomized controlled trial compared percutaneous transluminal angioplasty (PTA) with best medical treatment in 17 patients with IC and reported significant increase in ABPI in the PTA group only (0.63-1.05; P ¼ .0004). 15 Borozan et al 23 observed a 72% initial ABPI improvement in 34% of patients with IC treated with PTA, followed by a significant deterioration of flow during the follow-up period. Continued hemodynamic success was maintained in 37%, and overall long-term success was 27% during a mean follow-up of 16 months.…”

“…Thirteen studies reported ankle brachial pressure indices (ABPIs) after revascularization. 11,20,23,24,13,22,18,21,17,31 Nine of these studies reported significant improvement in initial ABPI. 20,22,18,21,17,12,14,16,19 Overall, success in improving flow was lower in patients with CLTI compared to patients with IC at 1 to 12 months follow-up; Savolainen et al 16 performed revascularization on 55 cases (26 CLTI and 21 IC) and reported a better outcome in patients with IC compared to patients with CLTI.…”