1990, The British Journal of Radiology, 63, 919-921
DECEMBER 1990
VOLUME 63 NUMBER 756
The British Journal of Radiology Deterioration following delay in performing femoral angioplasty By J. A. Spencer, MRCP, FRCR and E. W. L Fletcher, MA, FRCR Department of Radiology, John Radcliffe Hospital, Oxford (Received February 1990 and in revised form July 1990) Abstract. It is not uncommon for a delay to occur between assessment arteriography and angioplasty attempt. We reviewed retrospectively the arteriograms of 61 patients where such a delay occurred to ass*ess progression of superficial femoral artery (SFA) disease in this interval. A mean delay of 14.6 days (range 2-60 days) occurred between arteriogram and angioplasty attempt. Arteriographic deterioration was found in six of 61 patients (9.8%) and in three this precluded angioplasty. Of the six patients four had initial arteriography via the same side as the SFA disease whilst two had arteriography via the contralateral femoral approach. We discuss the aetiology of this phenomenon and suggestions are made to reduce its incidence.
When there is delay between diagnostic lower limb arteriography and angioplasty attempt, arteriographic deterioration may occur in the interim. In certain cases angioplasty may no longer be possible. Early deterioration following arteriography has been previously reported (van Andel, 1980; Gallino et al, 1983) but without analysis of the influence of arterial puncture site or other patient factors in this progression to arterial occlusion. A retrospective study has been performed to assess the frequency of this early deterioration and its relationship to the site of arterial puncture and other variables at assessment arteriography.
influence of the puncture site, the patients were subdivided into those where the initial arteriogram puncture had been ipsilateral to the angioplasty attempt and those where it had been contralateral. The interval of delay and the age and sex of the patients were recorded. Where the arteriograms were scored into category 2 the patients' notes were studied to identify any initial or post-arteriogram complication which might have a bearing on the observed SFA deterioration. The extent and severity of SFA disease was compared with ageand sex-matched category 1 patients. Results
Patients and methods
The arteriography register of the department was examined retrospectively for a 2 year period to identify all patients with peripheral vascular disease where there had been an interval of greater than 24 h between the initial assessment arteriogram and the subsequent attempt at SFA angioplasty. Patients had initial transfemoral arteriography as in-patients. There was no specific policy during the period of study regarding side of puncture chosen for assessment arteriography. The appearances of the SFA at initial arteriography were compared with the direct pre-angioplasty femoral arteriogram. The arteriogram pairs were scored in two categories: (1) no difference; (2) worsening of the SFA appearances such that the angioplasty attempt was either more difficult or impossible. To assess the Address correspondence to Dr John A. Spencer, Department of Radiology, John Radcliffe Hospital, Headington, Oxford 0X3 9DU. Vol. 63, No. 756
Of the 61 patients whose arteriograms were assessed, 34 were female and 27 male. For 33 patients the assessment arteriogram puncture had been ipsilateral to the SFA intended for angioplasty and for 28 patients a contralateral puncture had been used. These subgroups are compared in Table I. Four of the six patients in whom deterioration of the SFA appearances occurred had an initial ipsilateral study but this observation was not statistically significant. Details of the arteriographic deterioration of these patients are shown in Table II. No immediate complications were recorded to account for these findings in five of the patients. A sixth patient whose SFA disease was contralateral to the initial rightsided puncture site experienced a general urticarial reaction during arteriography and was noted to be hypotensive at the end of the procedure. The event responded to intravenous fluids but this episode may have some bearing on the early progression to complete occlusion of his left SFA. There were no features on their assessment arteriograms to suggest more severe lesions in the 919
J. A. Spencer and E. W. L. Fletcher Table I. Incidence of arteriographic deterioration of SFA disease according to puncture site Site
Patients
Age (years)
Delay interval
Incidence
Ipsilateral Contralateral
33 28
67.2 mean (56-83) 72.5 mean (50-88)
13.7 days mean (2-58 days) 15.6 days mean (2-60 days)
4/33" 2/28
"Difference not statistically significant. Table II. Nature and significance of SFA deterioration Age (years)
Sex puncture outcome
Delay (days)
74
F
Ipsilateral
2
56
F
Ipsilateral
15
62
M
Ipsilateral
14
70
F
Ipsilateral
7
73
M
Contralateral
25
83
M
Contralateral
7
Deterioration Longer occlusion (3 cm into 5 cm) Multiple stenoses into short occlusion (3 cm) Short stenosis into occlusion from origin Two short stenoses into occlusion from origin Multiple stenoses into long occlusion (10 cm) Single short stenosis into occlusion from origin"
Successful angioplasty Successful angioplasty Angioplasty surgery Angioplasty surgery Angioplasty surgery Angioplasty surgery
impossible, successful impossible, unfit for deferred, successful impossible, unfit for
"Patient experienced hypotensive episode during arteriography.
complications group than individuals showing no worsening of arteriographic appearances. The patients had an average age (69.7 years) similar to that of the overall study group and had no other specific risk factors, e.g. diabetes mellitus. Discussion
Femoro-popliteal angioplasty is now performed in most radiology departments and its use has grown rapidly in recent years (Cumberland, 1988). A close liaison and understanding is required between radiologist and vascular surgeon to maximize its benefits and to define clearly the role and capability of angioplasty in each centre. Grading systems have been described to assess suitability of patients for angioplasty (Campbell et al, 1988). The patient is best served when assessment arteriography can proceed to angioplasty attempt without delay. With this in mind the identification of patients for whom SFA-angioplasty would be the treatment of choice and the freedom to proceed are as important to the radiologist as the arteriographic delineation of suitable lesions. There are important implications for the provision of space on arteriography lists and a need for prior informed consent to minimize delays. We believe that the incidence of early deterioration in the SFA shown in this series makes it important to reduce the need for interval angioplasties. The aetiology of early deterioration in the SFA following arteriography is unclear. The early occurrence 920
of deterioration suggests it could be a true complication of arteriography rather than inevitable progression of SFA disease. Serial arteriographic studies in patients with lower limb arterial disease suggest a slow progression of the atheromatous disease process (Dawson & Raphael, 1968). The commonest deterioration in the SFA was of irregularity or stenosis proceeding to occlusion during a follow-up of 2 years. Similar deterioration from femoral artery stenosis to complete occlusion was noted in 53% of cases with an arteriographic follow-up of 25 months (Kuthan et al, 1971). The possibility that the arteriographic study itself may precipitate or accelerate this deterioration has been previously postulated (van Andel, 1980). In his series of six cases, deterioration was noted after ipsilateral, contralateral or translumbar puncture and it was thus suggested that the ionic contrast medium was the likely cause of damage. Our series also failed to demonstrate a statistically significant correlation with puncture site. Other authors have been reluctant to ascribe the acceleration of the obstructive process to the arteriography (Gallino et al, 1983). Deterioration was described in 18% of their patients restudied at a mean interval of 7 weeks. No relationship to puncture site or severity of stenosis was indicated. Early thrombosis of the common femoral artery is usually attended with obvious clinical features of arterial obstruction in the limb (Sigstedt & Lunderquist, 1978). The results of occlusion of an already diseased SFA are not so well documented and are probably The British Journal of Radiology, December 1990
Deterioration following delay in performing angioplasty
influenced by the extent of collateral circulation. None of our patients reported a clinical deterioration in accordance with previous reports (van Andel, 1980). Interestingly, his patients were either anti-coagulated or treated with anti-platelet medication in the interval between arteriography and angioplasty attempt but thrombotic deterioration still occurred. Arteriographic techniques have been refined in recent years with the use of smaller calibre catheters and nonthrombogenic guidewires. The introduction of lowosmolar contrast media and digital subtraction techniques (as used in our series) have further reduced the endothelial insult. Nevertheless, 10% of patients have been shown to have early and significant arteriographic deterioration following their assessment study. The exact cause for this remains unclear. Arteriography has been likened to "a squall shaking a ripe apple from a tree which would have fallen itself in due time" (van Andel, 1980). Angioplasty should follow arteriographic assessment with the minimum of delay before the apple turns rotten!
Vol. 63, No. 756
Acknowledgments We would like to thank the Nuffield Department of Surgery for permission to study their patients. References CAMPBELL, W. B., HIGGINS, J. R. A., BARKER, C. S., VON EICHSTORFF, P. & FLETCHER, E. W. L., 1988. Grading for
angioplasty. Clinical Radiology, 39, 516-518. CUMBERLAND, D. C , 1988. Peripheral angioplasty—10 years on. Clinical Radiology, 39, 573-574. DAWSON, J. M. & RAPHAEL, M. J., 1968. Serial aortography in
the study of peripheral vascular disease. British Journal of Radiology, 41, 333-340. GALLINO, A., MAHLER, F. & PROBST, P., 1983. Progression to
total occlusion of lower limb arterial stenoses selected for percutaneous transluminal angioplasty. Lancet, i, 59-60. KUTHAN, F . , BURKHALTER, A . , BAITSCH, R., LUDIN, H . &
WIDMER, L. K., 1971. Development of occlusive arterial disease in the lower limbs. Archives of Surgery, 103, 545-547. SIGSTEDT, B. & LUNDERQUIST, A., 1978. Complications of
angiographic examination. American Journal of Roentgenology, 130, 455-460. VAN ANDEL, G. J., 1980. Arterial occlusion following angiography. British Journal of Radiology, 53, 747-753.
921
DECEMBER 1990
VOLUME 63 NUMBER 756
The British Journal of Radiology Deterioration following delay in performing femoral angioplasty By J. A. Spencer, MRCP, FRCR and E. W. L Fletcher, MA, FRCR Department of Radiology, John Radcliffe Hospital, Oxford (Received February 1990 and in revised form July 1990) Abstract. It is not uncommon for a delay to occur between assessment arteriography and angioplasty attempt. We reviewed retrospectively the arteriograms of 61 patients where such a delay occurred to ass*ess progression of superficial femoral artery (SFA) disease in this interval. A mean delay of 14.6 days (range 2-60 days) occurred between arteriogram and angioplasty attempt. Arteriographic deterioration was found in six of 61 patients (9.8%) and in three this precluded angioplasty. Of the six patients four had initial arteriography via the same side as the SFA disease whilst two had arteriography via the contralateral femoral approach. We discuss the aetiology of this phenomenon and suggestions are made to reduce its incidence.
When there is delay between diagnostic lower limb arteriography and angioplasty attempt, arteriographic deterioration may occur in the interim. In certain cases angioplasty may no longer be possible. Early deterioration following arteriography has been previously reported (van Andel, 1980; Gallino et al, 1983) but without analysis of the influence of arterial puncture site or other patient factors in this progression to arterial occlusion. A retrospective study has been performed to assess the frequency of this early deterioration and its relationship to the site of arterial puncture and other variables at assessment arteriography.
influence of the puncture site, the patients were subdivided into those where the initial arteriogram puncture had been ipsilateral to the angioplasty attempt and those where it had been contralateral. The interval of delay and the age and sex of the patients were recorded. Where the arteriograms were scored into category 2 the patients' notes were studied to identify any initial or post-arteriogram complication which might have a bearing on the observed SFA deterioration. The extent and severity of SFA disease was compared with ageand sex-matched category 1 patients. Results
Patients and methods
The arteriography register of the department was examined retrospectively for a 2 year period to identify all patients with peripheral vascular disease where there had been an interval of greater than 24 h between the initial assessment arteriogram and the subsequent attempt at SFA angioplasty. Patients had initial transfemoral arteriography as in-patients. There was no specific policy during the period of study regarding side of puncture chosen for assessment arteriography. The appearances of the SFA at initial arteriography were compared with the direct pre-angioplasty femoral arteriogram. The arteriogram pairs were scored in two categories: (1) no difference; (2) worsening of the SFA appearances such that the angioplasty attempt was either more difficult or impossible. To assess the Address correspondence to Dr John A. Spencer, Department of Radiology, John Radcliffe Hospital, Headington, Oxford 0X3 9DU. Vol. 63, No. 756
Of the 61 patients whose arteriograms were assessed, 34 were female and 27 male. For 33 patients the assessment arteriogram puncture had been ipsilateral to the SFA intended for angioplasty and for 28 patients a contralateral puncture had been used. These subgroups are compared in Table I. Four of the six patients in whom deterioration of the SFA appearances occurred had an initial ipsilateral study but this observation was not statistically significant. Details of the arteriographic deterioration of these patients are shown in Table II. No immediate complications were recorded to account for these findings in five of the patients. A sixth patient whose SFA disease was contralateral to the initial rightsided puncture site experienced a general urticarial reaction during arteriography and was noted to be hypotensive at the end of the procedure. The event responded to intravenous fluids but this episode may have some bearing on the early progression to complete occlusion of his left SFA. There were no features on their assessment arteriograms to suggest more severe lesions in the 919
J. A. Spencer and E. W. L. Fletcher Table I. Incidence of arteriographic deterioration of SFA disease according to puncture site Site
Patients
Age (years)
Delay interval
Incidence
Ipsilateral Contralateral
33 28
67.2 mean (56-83) 72.5 mean (50-88)
13.7 days mean (2-58 days) 15.6 days mean (2-60 days)
4/33" 2/28
"Difference not statistically significant. Table II. Nature and significance of SFA deterioration Age (years)
Sex puncture outcome
Delay (days)
74
F
Ipsilateral
2
56
F
Ipsilateral
15
62
M
Ipsilateral
14
70
F
Ipsilateral
7
73
M
Contralateral
25
83
M
Contralateral
7
Deterioration Longer occlusion (3 cm into 5 cm) Multiple stenoses into short occlusion (3 cm) Short stenosis into occlusion from origin Two short stenoses into occlusion from origin Multiple stenoses into long occlusion (10 cm) Single short stenosis into occlusion from origin"
Successful angioplasty Successful angioplasty Angioplasty surgery Angioplasty surgery Angioplasty surgery Angioplasty surgery
impossible, successful impossible, unfit for deferred, successful impossible, unfit for
"Patient experienced hypotensive episode during arteriography.
complications group than individuals showing no worsening of arteriographic appearances. The patients had an average age (69.7 years) similar to that of the overall study group and had no other specific risk factors, e.g. diabetes mellitus. Discussion
Femoro-popliteal angioplasty is now performed in most radiology departments and its use has grown rapidly in recent years (Cumberland, 1988). A close liaison and understanding is required between radiologist and vascular surgeon to maximize its benefits and to define clearly the role and capability of angioplasty in each centre. Grading systems have been described to assess suitability of patients for angioplasty (Campbell et al, 1988). The patient is best served when assessment arteriography can proceed to angioplasty attempt without delay. With this in mind the identification of patients for whom SFA-angioplasty would be the treatment of choice and the freedom to proceed are as important to the radiologist as the arteriographic delineation of suitable lesions. There are important implications for the provision of space on arteriography lists and a need for prior informed consent to minimize delays. We believe that the incidence of early deterioration in the SFA shown in this series makes it important to reduce the need for interval angioplasties. The aetiology of early deterioration in the SFA following arteriography is unclear. The early occurrence 920
of deterioration suggests it could be a true complication of arteriography rather than inevitable progression of SFA disease. Serial arteriographic studies in patients with lower limb arterial disease suggest a slow progression of the atheromatous disease process (Dawson & Raphael, 1968). The commonest deterioration in the SFA was of irregularity or stenosis proceeding to occlusion during a follow-up of 2 years. Similar deterioration from femoral artery stenosis to complete occlusion was noted in 53% of cases with an arteriographic follow-up of 25 months (Kuthan et al, 1971). The possibility that the arteriographic study itself may precipitate or accelerate this deterioration has been previously postulated (van Andel, 1980). In his series of six cases, deterioration was noted after ipsilateral, contralateral or translumbar puncture and it was thus suggested that the ionic contrast medium was the likely cause of damage. Our series also failed to demonstrate a statistically significant correlation with puncture site. Other authors have been reluctant to ascribe the acceleration of the obstructive process to the arteriography (Gallino et al, 1983). Deterioration was described in 18% of their patients restudied at a mean interval of 7 weeks. No relationship to puncture site or severity of stenosis was indicated. Early thrombosis of the common femoral artery is usually attended with obvious clinical features of arterial obstruction in the limb (Sigstedt & Lunderquist, 1978). The results of occlusion of an already diseased SFA are not so well documented and are probably The British Journal of Radiology, December 1990
Deterioration following delay in performing angioplasty
influenced by the extent of collateral circulation. None of our patients reported a clinical deterioration in accordance with previous reports (van Andel, 1980). Interestingly, his patients were either anti-coagulated or treated with anti-platelet medication in the interval between arteriography and angioplasty attempt but thrombotic deterioration still occurred. Arteriographic techniques have been refined in recent years with the use of smaller calibre catheters and nonthrombogenic guidewires. The introduction of lowosmolar contrast media and digital subtraction techniques (as used in our series) have further reduced the endothelial insult. Nevertheless, 10% of patients have been shown to have early and significant arteriographic deterioration following their assessment study. The exact cause for this remains unclear. Arteriography has been likened to "a squall shaking a ripe apple from a tree which would have fallen itself in due time" (van Andel, 1980). Angioplasty should follow arteriographic assessment with the minimum of delay before the apple turns rotten!
Vol. 63, No. 756
Acknowledgments We would like to thank the Nuffield Department of Surgery for permission to study their patients. References CAMPBELL, W. B., HIGGINS, J. R. A., BARKER, C. S., VON EICHSTORFF, P. & FLETCHER, E. W. L., 1988. Grading for
angioplasty. Clinical Radiology, 39, 516-518. CUMBERLAND, D. C , 1988. Peripheral angioplasty—10 years on. Clinical Radiology, 39, 573-574. DAWSON, J. M. & RAPHAEL, M. J., 1968. Serial aortography in
the study of peripheral vascular disease. British Journal of Radiology, 41, 333-340. GALLINO, A., MAHLER, F. & PROBST, P., 1983. Progression to
total occlusion of lower limb arterial stenoses selected for percutaneous transluminal angioplasty. Lancet, i, 59-60. KUTHAN, F . , BURKHALTER, A . , BAITSCH, R., LUDIN, H . &
WIDMER, L. K., 1971. Development of occlusive arterial disease in the lower limbs. Archives of Surgery, 103, 545-547. SIGSTEDT, B. & LUNDERQUIST, A., 1978. Complications of
angiographic examination. American Journal of Roentgenology, 130, 455-460. VAN ANDEL, G. J., 1980. Arterial occlusion following angiography. British Journal of Radiology, 53, 747-753.
921
![[Laser angioplasty of the femoral artery following stent implantation].](/assets/img/hold.png)
