W. D. Jeans

The role of balloon angioplasty in the management of lower limb ischaemia

Three hundred and twenty-three angioplasties (159 iliac; 164 femoro-popliteal) were performed for lower limb ischaemia on 253 consecutive patients from 1980-86. The mean resting ankle/brachial pressure index (ABPI) was increased at one month in open angioplasties as follows: Femoro-popliteal 0.56-0.82; iliac with open superficial femoral artery (SFA) 0.7-0.95; iliac with occluded SFA 0.52-0.63. Successful angioplasty virtually abolished the post-exercise fall in ABPI except for patients having iliac dilations when multisegment disease was present. At 5 years, cumulative patency was 72% for iliac angioplasty and 53% for femoro-popliteal angioplasty. The results of angioplasty were compared with operative arterial reconstructions during 1985. Eighty-eight (91%) of 96 surgical bypasses were alive and patent at hospital discharge and 44 (71%) of 62 angioplasties were patent at 1 month. There were many fewer complications with angioplasty which involved a much shorter hospital stay (2 days vs 16 days).

Percutaneous transluminal angioplasty for lower limb ischaemia

Percutaneous transluminal angioplasty (PTA) is increasingly performed for lower limb ischaemia of all severities, despite the absence of controlled data demonstrating its efficacy. The aim of this study was to examine the indications and outcome for lower limb ischaemia over a 16‐year period.Forty successful percutaneous transluminal angioplasties (PTA) were performed in the iliac and femoropopliteal segments of 33 patients with lower limb ischaemia. There was immediate symptomatic relief in 37 limbs (92 per cent) although 7 relapsed and 5 patients required reconstructive arterial surgery within a month of PTA. Objective testing showed that the longer term relapse rate (median follow-up 12 months) was low (10 per cent). Despite a significant incidence of early complications and relapse, PTA provided a good long term result in the majority of patients treated.

Carotid artery disease: A prospective evaluation of pulsed doppler imaging

Abstract Ultrasonic imaging of the carotid artery bifurcation using a 30 channel pulsed Doppler system has been studied in a prospective trial. The results were compared to X-ray contrast angiography. Ninety per cent of the lesions of less than 50% were detected, as were all total occlusions of the internal carotid artery. The overall sensitivity was 93% and specificity 100%. Lateral ultrasonic scans were important in detecting lesions of less than 50% stenosis providing the diagnostic information in 48% of these vessels. The ability to identify both low and high grade stenoses with this system provides a basis for routine screening of patients with suspected carotid disease.

Failure of peripheral arterial balloon angioplasty: does platelet deposition play a role?

The pathophysiological response to peripheral percutaneous transluminal balloon angioplasty in 20 patients was investigated using 111-Indium labelled platelets. Platelet deposition was quantified by measuring the degree of radioactivity uptake at angioplasty and control sites using a computer linked system and expressing the uptake as a ratio of angioplasty/control. Following platelet labelling, scans were performed before angioplasty and at 1, 24 and 48 h after angioplasty. To assess patency of the angioplasty, ankle brachial Doppler pressure indices were performed and supported by repeat angiograms if doubt of patency existed. All patients were followed-up at 1 week, 1 month and 6 months to correlate the degree of early platelet uptake with failure. The mean +/- sem platelet radioactivity ratio at the angioplasty site increased from 1.1 +/- 0.1 prior to the procedure to a peak of 2.1 +/- 0.3 at 1 h (p less than 0.01), 1.6 +/- 0.2 at 24 h (p less than 0.05), and 1.7 +/- 0.3 at 48 h (p less than 0.05). Angioplasties that failed within 6 months tended to have a higher maximum early platelet uptake (3.1 +/- 0.6) compared to successful angioplasties (1.9 +/- 0.3) but the difference was not significant in the numbers studied. This study provides a suitable model to assess the role of platelet accumulation in angioplasty failure and the influence of various antiplatelet regimes.

Persistent bilateral sciatic arteries—an unusual presentation

A 20-year-old m an suddenly developed a cold white painful left lower leg after playing football a l though there was no history of t rauma. On examinat ion no pulses were palpable or detectable with Doppler u l t rasound below the left c o m m o n femoral artery. A right t ransfemoral lumbar aor togram (TFLA) demonstra ted bilateral persistent sciatic arteries with intimal irregularity at the level of the ace tabulum on the left (Fig. 1) and occlusion of all 3 calf vessels (Fig. 2). The superficial femoral ar tery was complete on the right, rejoining the sciatic ar tery at the knee but was incomplete on the left (Fig. 3). A diagnosis of thrombosis and subsequent embolism at the site of an intimal tear was made and a low dose infusion of streptokinase 6 0 0 0 uni ts /h commenced via a catheter advanced down to the popliteal artery. After 24 h the left foot was w a r m and pink but still pulseless and the streptokinase infusion was replaced by an in t ravenous heparin infusion 40 000 uni t s /24 h for 5 days. However, the foot again became critically ischaemic with rest pain and a Doppler pressure index of only 0.39. A repeat TFLA 1 week later showed tha t the irregularity in the left sciatic artery had been replaced by slight dilatation raising the possibility of an aneurysm a l though a mass in the buttock was not detectable clinically or by ul t rasound scanning. All 3 calf vessels were still occluded and so a lumbar sympathec tomy and popliteal embolectomy was performed. Organised th rombus was retrieved

Ultrasonic Doppler Scanning and B Mode Imaging of the Carotic Artery

Cerebral ischaemic attacks may be due to carotid bifurcation disease (3, 4, 6, 10) from emboli arising from atheromatous ulcers or haemodynamically significant stenosis or occlusion of the internal carotid artery (ICA). The need to determine the presence and nature of carotid lesions has been increased with the success of carotid endarterectomy in preventing stroke (8). While preoperative evaluation requires angiography for full assessment of extra- and intracranial vessels, it is not suitable to screen all patients with suspected cervical carotid vessel disease, due to the associated risks (7).