Complications of Femoropopliteal Interventions for Occlusive Disease

Introduction

There has been a dramatic change over the past several decades in management of patients with femoropopliteal occlusive disease transitioning from open to minimally invasive endovascular repair. Optimal medical therapy continues to be the first-line therapy for patients with claudication caused by femoropopliteal disease. This includes smoking cessation and cardiovascular risk reduction, including antiplatelet therapy, cholesterol manipulation, exercise therapy, and oral statins. Supervised exercise programs have proven to be efficacious, but they require consistent participation from highly motivated patients. Revascularization may be appropriate in patients with claudication who still have lifestyle altering symptoms despite medical management. Patients with critical limb ischemia (CLI) require intervention to achieve limb salvage. These patients usually have multilevel vascular disease and often require complex procedures.

Currently, in many centers, endovascular management of superficial femoral artery (SFA) and proximal popliteal lesions is the first-line therapy regardless of degree of stenosis, extent of calcification, total plaque occlusion, or length of the lesion.

Plaque etiology and composition impacts on the ability to perform endovascular procedures. Lesions can be composed of smooth muscle cell intimal hyperplasia, calcific lesions, thrombotic material, arterial necrotic core material, and a combination. The plaque constituents also impact procedure success and long-term patency. Studies have shown that the greater extent of calcification, the less the likelihood of immediate and long-term success.

Patient Evaluation

Many medical processes can cause lower extremity symptoms, and a careful history and physical help clarify the potential etiology. If there is concern for peripheral artery disease (PAD), we generally perform noninvasive vascular laboratory studies to evaluate further. We have found that these studies can accurately identify the arterial occlusive lesions and direct intervention. Arterial duplex confirms the location of the lesions and the extent and degree of calcification. If duplex reveals a long segment calcific SFA occlusion and an adequate venous conduit, we schedule the hybrid angiographic suite for diagnostic angiography and potential endovascular or open bypass. Other vascular surgeons and interventionalists have reported added benefit to preintervention CT angiography of the aorta and lower extremities, including more sizing of balloons and stents.

Arterial Access

In our institution, all arterial access is performed under ultrasonic guidance. The common femoral artery (CFA) is accessed antegrade or retrograde with micropuncture system. To confirm location and orientation, we pass the inner dilator of the micropuncture sheath into the femoral vessel and perform oblique angiogram, confirming optimal access. The micropuncture sheath with the inner and outer dilators reconnected is reinserted and the system exchanged to a 0.035′′ wire and 4–5-French sheath.

Access for femoropopliteal occlusive lesions are routinely performed antegrade or retrograde, with the approach tailored to patient anatomy. Antegrade access is used with patent aortoiliac, CFA, and proximal SFA, and planned intervention in mid-distal SFA, popliteal, or tibial vessels. Antegrade access allows greater “pushability” to traverse arterial total occlusions and control of the wire and catheter torque for selective catheterization of branch vessels. Steep aortic bifurcations and extremely tall patients, where catheter length becomes an issue, are well served by antegrade approach. Possible drawbacks are a higher rate of hematoma and pseudoaneurysm, although this may have abated in more recent series. Antegrade access can be more uncomfortable for the operator, as most endovascular suites are better oriented to facilitate retrograde femoral access. To maintain the usual orientation of controls and not have to work around the head and upper body of the patient, we frequently place a longer sheath into the proximal SFA, using an 0.035′′ support wire with approximately 20 cm of sheath externalized. The sheath is then gently curved to the patient’s contralateral groin in an approximation of up-and-over position. An occlusive Ioban drape secures this in place. This allows direct access from the more conventional retrograde approach, with added stability.

Similar technique is used for retrograde access. Retrograde access allows visualization of the suprarenal, perivisceral, aortoiliac inflow regions, and bilateral lower extremity arterial run-off vessels. Aorto-iliac angulation and calcification can make retrograde access more challenging. Once aortoiliac angiography has been completed, angiography of the contralateral lower extremity is performed. It is critical that angiography be carried out to the level of the foot to have a thorough understanding of the vasculature of the patient. To facilitate higher-quality imaging and decrease contrast load, imaging is performed from the contralateral external iliac artery. If the SFA is patent, the catheter is advanced to the popliteal over a wire and run-off of tibial and pedal vessels performed. If there is SFA occlusion, better visualization of the popliteal and tibial vessels may require a more proximal catheter in the external iliac artery, such that collateralization from the profunda femoral artery (PFA) allows visualization of the popliteal through geniculate vessels. Severe angulation within the aortoiliac segment can make passage of a sheath more challenging. Options for facilitating placement of an up-and-over sheath include positioning a wire within the contralateral distal SFA. If that is unsuccessful, passing a stiffer catheter with a more supportive wire, such as Rosen or Amplatz may facilitate sheath passage. If the sheath will still not pass, we take a long dilator and pass it over the stiffer wire into the contralateral iliac system. With the dilator in place, the shorter sheath can be advanced over the shoulders of the dilator into the contralateral iliac artery. Additionally, by separating the dilator and sheath slightly, it is often possible to “walk” the sheath over steep bifurcations. Finally, if the sheath will not advance, contralateral femoral access can be obtained and a small sheath inserted, snaring the wire. With through-and-through access, the sheath can be advanced into the iliac arteries.