Infrainguinal Arterial Duplex Guided Balloon Angioplasty (DGBA): An Alternative Approach For Patients With Renal Insufficiency

Back to 33rd Annual Symposium
Back to Final Program

Enrico Ascher, MD, Natalia Markevich, MD, RVT, Anil P. Hingorani, MD, Richard W. Schutzer, MD, Suresh Nahata, MD, Manikyam Mutyala, MD.
Maimonides Medical Center, Brooklyn, NY, USA.

Purpose: The technique of balloon angioplasty of infrainguinal arteries requires the use of standard arteriography and fluoroscopic guidance. We attempted to perform this procedure under duplex guidance to avert the use of nephrotoxic contrast material in patients with renal insufficiency.
Methods: Over the last 16 months, 28 patients (17 males) with serum creatinine ≥ 1.5 mg/DL underwent 37 lower extremities DGBAs at our institution. Age ranged from 58 to 92 years (74±9 years). Disabling claudication was the indication in 24 cases (65%) and critical ischemia in 13 cases. Preoperative duplex arterial mapping showed severe superficial femoral artery (SFA) and/or popliteal artery (PA) stenoses in all cases. Seven procedures (19%) were performed for restenosis. The ipsilateral common femoral artery (CFA) was cannulated in 32 cases (86%) and contralateral CFA in 5 cases (14%) under direct duplex visualization. Contralateral common iliac artery (CIA) cannulations were performed with help of fluoroscopy and a guiding catheter. Using sonographic visualization a guide wire was directed into the origin of the SFA, across the diseased segment and into the popliteal artery with the help of a guiding catheter. The diseased segment was then balloon dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex. Whenever indicated, stents were placed under duplex guidance. Completion duplex examinations and ankle/brachial indices (ABIs) were obtained in all cases. All cases were performed under local anesthesia.
Results: Thirty-day survival was 100%. Local complications included one open exploration for expanding hematoma. The overall immediate technical success was achieved in all cases. Placement of intraluminal stents were deemed appropriate in 21/37 (57%) cases. The 1-month patency and limb salvage rates were 100%. Pre-procedure and post-procedure ABIs ranged from 0.2 to 0.8 (mean 0.56±0.16) and 0.67 to 1.2 (mean 0.9±0.12), respectively (p<0.0001).
Conclusion: DGBA appears to be a safe and effective technique that allows renal patients to experience continued limb salvage and relief from claudication without the risk of developing dye-induced acute renal failure. Other advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, confirmation of the adequacy of the technique by hemodynamic and imaging parameters and avoidance of radiation.