Peripheral Arterial Disease Diagnosis and Intervention

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What is the appropriate landmark for a femoral artery puncture?

Some risks of arteriography can be minimized by properly selecting the puncture site. Above the inguinal canal, the common femoral artery becomes the external iliac artery and dives posteriorly. Punctures above the inguinal canal may be problematic for several reasons. Because the artery is deep in relation to the puncture site, manual compression may be difficult, leading to a hematoma or arterial pseudoaneurysm. In the event of an access site complication that requires surgical intervention, the surgical approach for puncture above the inguinal ligament is more involved. A puncture that is too low may result in an arteriovenous fistula (AVF). The inguinal crease is a landmark that is commonly used for femoral artery puncture, but this is a very inaccurate estimate for the location of the inguinal ligament, especially in obese patients. The best landmark is the middle of the medial third of the femoral head identified fluoroscopically ( Figure 70-1 ). Ultrasonography (US) may also be used to guide access.

2

If the femoral artery cannot be accessed, what are other options to obtain access for an arteriogram?

Multiple options for access may exist in any given patient. The appropriate access site depends on the patient's symptoms, intended procedure, prior surgical history, known sites of arterial occlusion, and clinical setting. A brachial artery approach may be used if a femoral approach is impossible. Other access options include direct puncture of bypass grafts, direct translumbar aortic puncture, radial artery access, and retrograde popliteal or dorsalis pedis access.

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If a brachial approach must be used, is the right or left arm used?

A left brachial approach is preferred. A catheter placed from the left arm passes the left vertebral artery origin but not that of the left common carotid artery; this may reduce the risk of stroke.

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What are some complications unique to brachial access?

There is a small risk of stroke associated with brachial access. The arm cannot tolerate large hematomas, and bleeding after removal of a catheter or sheath may result in a compartment syndrome. If a hematoma does develop, it must be followed up carefully to ensure that neurovascular compromise does not occur. Surgical evacuation of the hematoma may be required to prevent a neurologic deficit. In recent years, many practitioners have shifted to radial access, because there is theoretically less risk of limb ischemia and upper extremity neurologic complications.

5

What is claudication?

Claudication is derived from the Latin verb claudicare , which means “to limp.” Claudication describes exercise-induced leg pain secondary to peripheral arterial disease (PAD). Patients with claudication typically complain of a burning or aching sensation in the thigh or calf, which starts after walking a predictable distance and remits with rest. With advanced disease, there may be progression to rest pain, skin ulceration, and tissue loss.

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What are the risk factors for PAD and claudication?

Risk factors include hypertension, diabetes mellitus, high cholesterol levels, cigarette smoking, and advanced age. Claudication is also more likely in individuals who already have atherosclerosis in other arteries, such as the coronary or carotid arteries.

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Does the location of leg pain suggest the location of arterial stenosis?

Leg pain usually occurs downstream from hemodynamically significant stenoses. For example, calf pain may result from disease of the superficial femoral artery, whereas thigh or buttock pain may be caused by iliac arterial disease.

8

Why is it important to identify patients with claudication?

PAD affects more than 10 million Americans, and its prevalence is increasing. PAD is an important marker for many other serious conditions, including coronary artery disease, cerebrovascular disease, aneurysms, diabetes mellitus, and hypertension. Patients with PAD have a 4- to 6-fold increased cardiovascular mortality compared to age-matched controls. The mortality rate for patients with claudication may be 75% at 15 years after diagnosis of PAD. Early diagnosis of the disease gives patients the chance to modify their atherosclerotic risk factors and to reduce their risk of coronary and carotid artery disease.

9

What is the Fontaine classification?

The Fontaine classification is a widely used classification system for lower extremity ischemia. It describes four stages based on signs and symptoms.

• Stage 1 is asymptomatic disease.

• Stage 2a is intermittent claudication when walking more than 200 m.

• Stage 2b is intermittent claudication when walking less than 200 m.

• Stage 3 is rest pain.

• Stage 4 is tissue necrosis or gangrene.

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What is the Rutherford-Becker classification system?

This is another classification system for chronic limb ischemia. It is popular in the United States and is based on clinical and objective criteria ( Table 70-1 ).

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