1992, The British Journal of Radiology, 65, 140-142

Percutaneous transluminal angioplasty: pain during balloon inflation By Yukunori Korogi, MD, Mutsumasa Takahashi, MD, Hiromasa Bussaka, MD and Yoshimi Hatanaka, MD Department of Radiology, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto 860, Japan {Received 20 November 1990 and in final form 16 August 1991, accepted 23 August 1991) Keywords: Arteries, Transluminal angioplasty, Angiography, Complication, Arteries, Stenosis

Abstract. The pain during the balloon dilatation of angioplasty was evaluated prospectively to assess its clinical significance. In 54 angioplasties, no pain was observed in 54%, mild pain in 20%, moderate pain in 11% and severe pain in 15%. Moderate or severe pain was observed in 39% of 28 iliac angioplasties and in 7% of 14 femoral angioplasties. There was a significant difference between the two groups. We did not find any significant correlation between the severity of pain and stenotic ratio before angioplasty. Severe pain may be a warning of severe dissection; in our study, all severe dissections were accompanied by severe pain without arterial rupture.

Patients often experience some degree of pain during inflation of balloons for angioplasty, not associated with clinical problems. However, some authors have suggested that severe pain may be an important warning of arterial rupture (Jensen et al, 1985; Chong et al, 1990). The frequency and severity of pain during balloon inflation has not been reported. We have evaluated prospectively the pain experienced by patients to determine its clinical significance.

tation and the luminal diameter after dilatation were correlated with severity of the pain. Severe dissection after dilatation was defined as an intimal dissection compromising flow and requiring further therapy, although intimal dissection itself was a common finding at the dilatation site. The unpaired Mest was used in the statistical evaluations. Results

In 54 angioplasties, no pain was observed in 29 dilatations (54%), mild pain in 11 (20%), moderate pain The study comprises 54 angioplasties in 44 patients in six (11%), and severe pain in eight (15%) dilatations. with atherosclerosis: 28 iliac, 14 femoral and 12 renal The pain was observed only during balloon inflation. In arterial dilatations. Technical failures such as subintimal a few patients, however, pain continued for several to passage of the guidewire or catheter were excluded in 10 s after deflation of the balloon. this study. Angioplasties were performed in a routine No dilated artery ruptured in this study. However, fashion under local anaesthesia (Korogi et al, 1987). severe dissection occurred in three dilatations (two iliac The balloon required was selected by measuring the and one femoral), and was associated with severe pain. diameter of the contralateral artery or the adjacent In these two patients with iliac angioplasty, no other patent portion of the vessel on the conventional angio- symptoms related to severe dissection were present. gram. The diameters of the balloons used were 6-8 mm They were referred for bypass surgery because of unsucin iliac angioplasty and 4-6 mm in femoral or renal cessful re-dilatation, which also produced severe pain. angioplasty. An oversized balloon was never used. The Another patient with femoral angioplasty complained of balloon was inflated by hand twice for 30 s, or several temporary pain in the lower leg after occurrence of times until the "waist" of the balloon disappeared under severe dissection, and immediate re-dilatation, which fluoroscopy. We did not use a pressure gauge because of did not produce severe pain, was performed successloss of feeling at inflation and dilatation of the stenosis. fully. Data of the re-dilatations are not included in this However, the syringe size used was larger than 10 ml evaluation. No overdistension was observed in our capacity to avoid excessive pressure. series. Analysis of the data regarding the site of dilatation Patients were asked to report any pain they experienced, and angiographers recorded the patient's distress demonstrated a significant difference between iliac and and motion during balloon inflations. The data were femoral angioplasties (p < 0.05) (Table I). Eleven of 28 scored from zero to 3 by the following criteria: (0) no iliac angioplasties (39%) had moderate or severe pain pain; (1) mild pain (no distress or motion); (2) moderate against only one of 14 femoral angioplasties (7%). pain (face being distorted or moving slightly); and (3) There was still a significant difference between the two when the three cases of severe dissection were excluded severe pain (giving a cry or major movement). The site of dilatation, the stenotic ratio before dila- from analysis (p < 0.05). Although the mean score was Materials and methods

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The British Journal of Radiology, February 1992

Pain during balloon dilatation Table I. Mean score of pain with regard to site of dilatation Site of dilation

Total

Mean score

Severity of pain (no. of patients) None

Mild

Moderate

Severe

Iliac Femoral Renal

28 14 12

10 10 9

7 3 1

5 0 1

6" 1* 1

1.25 0.43 0.50

Total

54

29

11

6

8

0.87

T w o cases of severe dissection. *One case of severe dissection. Table II. Mean score of pain with regard to stenotic ratio Stenotic ratio (%)

Total

Mean score

Severity of pain (no. of patients) None

Mild

Moderate

Severe

50-60 61-75 76-90 91-100

19 10 10 15

10 4 7 8

5 3 1 2

3 1 0 2

1 2 2" 3*

0.74 1.10 0.70 1.00

Total

54

29

11

6

8

0.87

T w o cases of severe dissection. One case of severe dissection.

ft

also low in renal angioplasty, there was no statistical significance between iliac and renal arterial dilatations because of small numbers. We did not find any significant correlation between the severity of pain and stenotic ratio before angioplasty (Table II). Severe stenosis did not necessarily cause severe pain. Discussion

Not only vasomotor nerves but also sensory nerves are present in the walls of blood vessels. However, these nerves are not found in the intima or media, but are present in the adventitia on electron microscopy (Bloom & Fawcettt, 1975). The sensory nerves are myelinated, and register a sensation of pain caused by a penetrating object or a sudden distension of the vessel (Rhodin, 1974). It has been suggested that pain during balloon inflation represents adventitial stretching (Katzen, 1983). Our previous study showed a varying degree of adventitial stretching as well as intimal dissection and medial overdistension after experimental angioplasty in rabbits (Korogi & Takahashi, 1987). In the large elastic arteries, such as the aorta, subclavian and common iliac arteries, there are more sensory nerves than in the more peripheral muscular arteries (Rhodin, 1974; Bloom & Fawcett, 1975). The significant difference between the iliac and femoral arteries may be explained by a different distribution of sensory nerves. Some authors have described severe pain as an important warning of arterial rupture, although this is an Vol. 65, No. 770

extremely rare complication. Patients often experience some degree of pain in many balloon angioplastic procedures (Jensen et al, 1985; Chong et al, 1990). Most interventional radiologists recognize that the pain during balloon inflation is usually of no clinical consequence. However, there has been no report about the exact frequency and severity of pain and its clinical significance in balloon angioplasty. Our evaluation revealed that the frequency of moderate or severe pain was up to 40% in iliac angioplasty, which might be much higher than previously expected. Severe pain may not be a warning of arterial rupture but of severe dissection; in our study all severe dissections were accompanied by severe pain without arterial rupture. In the iliac region, two of six cases (33%) with severe pain showed severe dissection, as did the one case in the femoral region (100%). Severe intimal dissection, not accompanied with clinical consequence, is presumed to occur much more frequently than arterial rupture. In conclusion, moderate or severe pain occurred in up to 40% of iliac angioplasties. There was a significant difference in incidence of pain during the balloon dilatation of iliac and femoral angioplasties, which may be explained by the different distribution of sensory nerves. Furthermore, severe pain may be a warning of severe intimal dissection. References BLOOM, W. & FAWCETT, D. W., 1975. Blood and lymph

vascular system. In A Text Book of Histology (W. B. Saunders, Philadelphia), pp. 384-426.

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Y. Korogi et al CHONG, W. K., CROSS, F. W. & RAPHAEL, M. J., 1990. Case

KOROGI, Y., TAKAHASHI, M., BUSSAKA, H., MIYAWAKI, M. &

report: Iliac artery rupture during percutaneous angioplasty. Clinical Radiology, 41, 358-359.

YAMASHITA, Y., 1987. Percutaneous transluminal angioplasty of the ilio-femoro-popliteal arteries: initial and long-term

JENSEN, S. R., VOEGELI, D. R., CRUMMY, A. B., TURNIPSEED, W. D., ACHER, C. W. & GOODSON, S., 1985. Iliac artery

results. Radiation Medicine, 5, 68-74. KOROGI, Y. & TAKAHASHI, M., 1987. Light and electron

rupture during transluminal angioplasty: treatment by embolization and surgical bypass. American Journal of Roentgenology, 145, 381-382. KATZEN, B. T., 1983. Transluminal angioplasty of the iliac arteries. In Transluminal Angioplasty, ed. by W. R. Castaneda-Zuniga (Thieme-Stratton, New York), pp. 93-101.

microscopic observations in atherosclerotic rabbits following experimental transluminal angioplasty. Acta Radiologica, 28, 323-328. RHODIN, J. A. G., 1974. Cardiovascular system. In Histology (Oxford University Press, New York), pp. 332-370.

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Percutaneous transluminal angioplasty: pain during balloon inflation.

The pain during the balloon dilatation of angioplasty was evaluated prospectively to assess its clinical significance. In 54 angioplasties, no pain wa...
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