TIBIAL ANGIOPLASTY  

By
Dr. Moustafa Abd Elhamid Elshal
Specialist of Vascular Surgery ,Endovascular Surgery and Diabetic Foot mangement
National Institute Of Diabetes and Endocrinology
Cairo - Egypt

Tele : 0113437474 - 0106011656

 

2010
In the name of ALLAH
the almighty and merciful
Review of Literature

# Surgical anatomy of lower limb arteries.

# Equipments for angioplasty.

# Techniques of tibial angioplasty.

# Transluminal versus subintimal angioplasty.

# Causes and mechanisms of restenosis after angioplasty.

# Surgery versus angioplasty in treatment of tibial

arteries diseases.
SURGICAL ANATOMY OF LOWER LIMB ARTERIES
1- Femoral Artery:

Is a continuation of the external

iliac. It begins behinnd the inguinal
ligament, midway between the
anterior superior iliac spine and the
pubic symphysis, enters and passes
through the adductor (subsartorial)
canal, and becomes the popliteal
artery as it passes through an opening
in adductor magnus near the junction
of the middle and distal thirds of the
thigh. (Gray and Lewis , 2004)
 2-Profunda femoris artery (deep femoral artery) :
Is a large branch that arises
laterally from the femoral
artery 3.5 cm distal to the
inguinal ligament and is the
main supply to the adductor,
extensor and flexor muscles; it
also anastomoses with the
internal and external iliac
arteries above and the popliteal
artery below it gives three
perforating branches, and the
profunda itself becomes the
fourth perforator.(Williams et
al., 1999).
 3-Popliteal artery:
Is the continuation of
the femoral artery, crosses
the popliteal fossa .The
artery is relatively tightened
at the adductor magnus
hiatus and again distally by
the fascia related to soleus .it
divides into the anterior and
posterior tibial arteries
(Valentine and Wind,
2003).
 4-Anterior Tibial Artery:
Is a branch of the
popliteal artery that arises at
the distal border of popliteus
Descending anteriorly on the
interossious membrane at the
ankle it is midway between the
malleoli, and continues on the
dorsum of the foot as the
dorsalis pedis artery
(Sinnatamby, 2000).
5-Posterior Tibial Artery:
Begins at the distal
border of popliteus,
between the tibia and
fibula. It descends medially
in the flexor compartment
and divides midway
between the medial
malleolus and the medial
tubercle of the calcaneus,
into the medial and lateral
plantar arteries (Williams
et al., 1999).
 6-PERONEAL ARTERY:
Arises from the
posterior tibial artery 2.5
cm distal to popliteus and
passes obliquely to the
fibula. Distally it is
overlapped by flexor
hallucis longus
(Valentine and Wind,
2003).
 EQUIPMENTS FOR ANGIOPLASTY
1-Choosing an imaging system:
Excellent imaging is the key to endovascular therapies . Both portable C-arm
and an angio suite imaging unit have specialized functions that are commonly
used during interventions . Despite the significant technical improvements in
the current model of C-arm systems, the image quality remains slightly
inferior to that obtained from the angio suite .A standard imaging suite image
intensifier is 15 inch in diameter. (Yao and Pearce, 2002).
2-Imaging table:
**Fixed tables: Are constructed of a non metallic carbon-fiber supported usually
at only one end These tables are relatively fragile and do not
support obese patients. (Yao and Pearce , 2002).

**Movable tables: Allow positioning of the patient in the horizontal plane .

They come with a set of bedside controls that also permit
selection of the radiographic settings including rotation,
image intensifier location and table height
.)Yao and Pearce , 2002(
3-Power injector: There are two methods for delivering contrast:
# Hand injection with a syringe For most small vessel and selective angiography,
hand injection is adequate.

# Electronically calibrated power injection for optimal opacification of high-flow

blood vessels like the aorta
(Kluge and Rauber et al., 2003).
4-Equipments of vessel puncture:
A-The single-wall puncture needle: is most familiar to surgeons and the
one most commonly used. It is a bevel-tipped 16- or 18-gauge hollow needle
.that accommodates a 0.035 inch guide wire

B- The Double-wall puncture needles: which are two component

systems that combine a blunt-tipped hollow needle with a bevel-tipped
stylet that projects slightly out the end of the needle

(Ayerdi and Hodgson , 2005).

5-Sheaths:
# Sheaths are essentially access to the vascular system placed at the time of
initial vascular access is achieved and removed after completion of the
diagnostic study or intervention.
# Diameters most commonly used are in the 5- to 6-French range (1 French =
0.33 mm or 0.013 inch).
# Placement of stents requires the use of sheaths in the 6F .
# The size designation denotes the internal diameter (ID) of the sheath, as
opposed to catheters which are sized in French by their outer diameters (OD).
(Kluge and Rauber et al.,
2003).
6-Wires:
# Major classification is often by size, grouping 0.035 inch and 0.014/0.018 in
diameter wires.
# Access wires for the femoral approach and for diagnostic angiography of large
and medium-sized vessels are usually 0.035 inches in diameter.
# Hydrophilic wires are essentially used in tortuous vessels, recanalization
work, are more difficult to handle potentially more traumatic, and should not
be used as routine access .
# 0.014/0.018-in systems are super tools for intervention on smaller vessels
These wires generally have a shapeable tip that is visible under fluoroscopy.
They are less traumatic than thicker wires and are conveniently paired with low-
profile balloons and stents that easily cross tight lesions.
(Hughes and Scott et al., 2000).
7-Balloons :
# Angioplasty balloons Made with a thin wall of materials such as polyethylene
terephthalate or nylon, they tend to maintain their shape and size under high
inflation pressure (typically 8-20 atm and sometimes as high as 30 atm).

# Of these 2 materials, polyethylene terephthalate is stronger and the balloon can

have a thinner wall and lower profile .

# Compliance refers to the relationship between changes in volume and pressure

Balloon compliance is also important when expanding a stent .

# The following equation defines the stress on a typical angioplasty balloon:

Radial (hoop) stress = (pressure × radius)/(2 × thickness)

# Cryoplasty balloons produce a cold thermal injury to the vessel by inflating with
liquid nitrous oxide that turns to gas. These balloons have recently received
considerable attention in the media, but their superiority remains unproven .

# Cutting balloons have blades that are brought into contact with the vessel wall
during inflation and are useful in resistant lesions.
# the Amphirion paclitaxel-eluting PTA balloon catheter. This is the first drug-
eluting catheter designed specifically to treat atherosclerosis in arteries located
below the knee. A proprietary coating that frees and separates paclitaxel molecules
and facilitates their absorption into the wall of the artery.
8-Stents:
# Vascular stents are metal frameworks that support the lumen from within.

# Stents work well to prevent acute recoil after angioplasty, maximize lumen
diameter, and “tack down” dissection flaps.

# Earlier stents were stainless steel, with newer designs favoring cobalt-chromium
alloys. The most biocompatible material has yet to be determined. Magnesium-
based and other absorbable stents are under investigation.

# Drug-eluting stents and newer stent designs have lower restenosis rates.

# Stents may be broadly classified as balloon- expandable or self-expanding

*Balloon-Expandable Stents
Balloon-expandable stents rely on inflation of an angioplasty balloon to expand the
stent from its collapsed configuration and push it into contact with the vessel wall
*Self-Expanding Stents
As the name implies, self-expanding stents are released from their constraining
delivery mechanism and expand within the vessel until the stent reaches its
predetermined maximum diameter or is constrained by the vessel wall.
# Nitinol stent derives its name from nickel-titanium/Naval Ordnance Laboratory,
referring to the components of the alloy and the site of its discovery in 1961.

# Nitinol stents are appealing because they revert to their original shape when
warmed to body temperature. This allows both a compact delivery system and an
outward radial force in the vessel after placement. The stents are MRI safe, flexible,
and foreshorten little. And usually have marker dots at both ends.
(Ayerdi and Hodgson,
2005).
Other Types of Stents :
stent grafts” 1-Covered Stents“
Are terms loosely used to describe metal stents that are either covered or
lined with fabric (usually polytetrafl uoroethylene).
Benefits include the ability to treat aneurysms and perforations while
maintaining lumen patency.

2- Drug-Eluting Stents
The most recent and dramatic advance in stent design is the drug-
eluting stent. These stents provide local release of a drug to prevent restenosis.
Agents used include the anti-proliferative drugs (paclitaxel).

However, they are expensive, and patients must remain on clopidogrel for 6
months after placement to prevent thrombosis
(Ayerdi and Hodgson, 2005).
TECHNIQUES OF TIBIAL ANGIOPLASTY
Endovascular therapy for infrapopliteal vascular disease is gaining acceptance as
there is growing evidence demonstrating its safety and effectiveness

: Indications and Patient Selection

# Indication for PTA of infrapopliteal vascular disease is in limb salvage
patients with (CLI). This patient often has limited surgical options.

# Extending the indications for endovascular interventions on the tibial

arteries to include lifestyle altering claudication.

# Technical and more importantly clinical success depends on the ability to

select cases which are most suitable for endovascular therapy.

# The ideal lesions for tibial angioplasty are focal stenoses with good distal
runoff.

# The necessity of establishing straight-line flow to the foot is another key

feature in tibial angioplasty for limb salvage.
(Lofberg and Karacagil et al.,
2000).
Techniques

1-Imaging:
• A high-quality digital subtraction angiography.
• Use of road-mapping greatly aids in performing the procedure.
• The preferred contrast agent for lower extremity arteriography is low-
osmolar, nonionic contrast material. (Kougias and Nguyen
et al., 2006)
2-Access:
Through an antegrade puncture of the ipsilateral common femoral artery. This
provides the greatest control to direct catheters and wires .
(Kougias and Nguyen et al., 2006)
Balloon Angioplasty-3:
# To cross infrapopliteal stenoses, 0.018-inch hi-torque floppy-tipped guide
wires are ideal. For difficult occlusions, hydrophilic guide wires are useful.

# PTA of infrapopliteal lesions are best accomplished using high-profile small

vessel balloons catheters ranging from 2.5 to 4.0 French.

# Inflation times of 5 to 10 seconds are usually adequate a balloon is

positioned in each one of the two vessels arising from the bifurcation. This
will protect both vessels from intimal dissection or embolization.

# In performing infrapopliteal PTA it is usually best to treat the proximal

lesions before the distal lesions for Prevention of thrombosis around the
proximal stenoses and better manipulation of the catheter and guide wire
when treating the distal lesions. (Pearce and Matsumura et al., 2000).
4-Stents :
stents have not been widely used in the infra-popliteal vessels. The primary
reason is because of the small caliber and slow flow in these vessels. Currently,
stents are only typically used below the knee when PTA fails, such in the case
of a flow limiting dissection or elastic recoil (Lipsitz and Veith et al., 2005).

Postprocedure Care-5:
includes bed rest, monitoring of vital signs, hydration, and observation for
complications.

Pharmacologic Agents-6:
Antispasmodics : use of intra-arterial nitroglycerin (100 microgm.) either
once vasospasm is seen.
Thrombolytics: catheter directed thrombolysis with urokinase is
appropriate.
Anticoagulation Agents: intravenous bolus of heparin (5,000 to 7,000 U)
after vascular assess is obtained. An additional 5,000 units may be needed
during the procedure postprocedure heparin may be continued overnight.
The routine use of postprocedure warfarin is not indicated
(Anand and Creager, 2000).
 Antiplatelet Agents:
# Aspirin is by far the most commonly used of the antiplatelet agents
available.

# Recently, clopidogrel (Plavix) has gained increased acceptance as an

antiplatelet agent .Clopidogrel has been shown to be superior to aspirin in
reducing the rates of all types of vascular occlusive events.

(Clark and Groffsky et al., 2001).

New approaches to infrapopliteal angioplasty
1-Laser :

laser athermic catheters and saline infusion

techniques can minimize thermal injury and
significantly reduce arterial dissection. Excimer
laser is a pulsed laser system working at a
wavelength of 308 nm, which ablates or vaporizes
the lesion material (De Sanctis, 2001).
2-Coated stents
Recently stents coated with a thin and highly
adherent film of Carbonfilm , a material which shows
excellent high haemocompatibility and mitigation of
inflammatory response (high biocompatibility)
(De Sanctis , 2001).

3-Absorbable stents

Recently a magnesium alloy absorbable stent

has been used in focal infrapopliteal stenoses in
patients with CLI. (Muradin and Bosch et al.,
2003).
 TRANSLUMINAL VERSUS
SUBINTIMAL ANGIOPLASTY
# Important determinants of successful percutaneous transluminal angioplasty
(PTA) are lesion location, length, plaque composition, and morphology.

# Pooled results of infrapopliteal PTA indicate 1, 3 and 5-year primary patency

rates of 65% to 77%, 48% to 66%, and 42% to 55%, respectively.

# Subintimal angioplasty, described by Bolia in 1989, is a variant of PTA that

allows the treatment of long occlusions when intraluminal wire crossing is not
possible. an extraluminal dissection is created and pass the occlusion, with re-
entry into the true lumen distally. Technical failure is mainly due to an inability to
re-enter the true lumen. 90% of the subintimal angioplasties were performed in
TASC D lesions, with skin ulceration or necrosis. Clinical success and limb salvage
at 2 years was 72% and 88%, respectively.
(Perera and Lyden, 2007).
Subintimal angioplasty of Peroneal artery
Factors Affecting Patency of Subintimal Angioplasty in Patients with Critical
Lower Limb Ischemia:

# The most important are the number of patent run-off vessels after the procedure
and the length of angioplasty.

# Neither gender nor any risk factor of atherosclerosis such as diabetes mellitus,
arterial hypertension, coronary artery disease and history of smoking, affect the
outcome.

# the patency rate of SIA with more than one run-off vessels at 12 months is 81%
compared to the 25% of SIA with one run-off vessel.

# None of the factors predisposing to atherosclerosis was found to affect the SIA
outcome. Arterial hypertension has been reported to increase the risk of occlusion
in claudicant patients .

# Smoking is not related to the angioplasty outcome but the continuation of

smoking after the procedure is related to a higher reocclusion rate.
(Lazaris and Salas et al., 2006).
 CAUSES AND MECHANISMS OF RESTENOSIS
AFTER ANGIOPLASTY
Cellular events in response to endovascular interventions:
Biological response to balloon angioplasty:
The objective of the balloon angioplasty is to exert a
dilating force on the endoluminal surface of a vessel at
the desired location. This causes desquamation of
endothelial cells (ECs) and histological damage
proportional to the diameter of the balloon and the
duration of the inflation.

The predominant effect of balloon angioplasty in

enlarging vessel lumen is by stretching the elastic
components of the arterial wall.

Inelastic portion of the plaque fracture or tear

results in a definite arterial wall dissection
histologically evident arterial dissection is nearly
present in all diseased vessels following balloon
angioplasty procedures.
(Kougias and Nguyen et al., 2006).
 The oxidative stress that follows angioplasty, invasion of neutrophils,
macrophages and T-lymphocytes, mobile vascular smooth muscle cells (SMCs)
which migrate close to the site of injury all these events favor restenosis, or intimal
hyperplasia.

Biological response to intraluminal stenting:

within 15 min following stent implantation, there is an accumulation of red
blood cells and platelets on the stent surface. At 24 h. , this cellular layer is
replaced by a layer of fibrin strands oriented in the direction of blood flow as the
positive electrical potential of the metallic stents attracts the negatively charged
circulating proteins on the stent surface. (Kougias and Nguyen et al. , 2006).

Stents placed into the venous system exhibit a faster rate of

endothelialization than do intra-arterial stents.(Kougias and Nguyen et al. ,
2006).

Soon after the intra-arterial stent deployment, the positive electrical

potential of the metal attracts the negatively charged circulating proteins to form
a thin layer of fibrinogen strands on the stent surface. The proteins neutralize the
stent surface and decrease thrombogenicity (Lee and David et al., 2004).
 Severe angiographic restenosis (arrow) is seen
within a Anterior tibial artery stent. 4 months following
implantation of a stent.(Kougias and Nguyen et al. ,
2006).

Ideally, stents should be deployed in such a way that the metal ends are
embedded deep enough into the vessel wall

The achievement of this ideal deployment is dependent on multiple factors:

the ratio of the diameter of the stent to that of the blood vessel, the depth of
penetration of the struts into the vessel wall, thickness of the struts, and the
composition and integrity of the intimal surface.

Stent struts will be embedded adequately if the final stent diameter is 10–
15% larger than the diameter of the adjacent vessel .
(Lee and David et al., 2004).
Mechanisms of Restenosis:

# Three mechanisms are responsible for the development of restenosis: elastic

recoil, intimal hyperplasia, and late vascular constriction.

# Restenosis is seen mainly in small-sized and medium-sized arteries.

(Sidawy and Weiswasser et al., 2002).

Vessel remodeling:

# Refers to a pattern of chronic over weeks or months changes of the structure

of the vessel wall that follows injury.

# The factors linked to remodeling after angioplasty include hemodynamic

changes in blood pressure, flow rates, patterns of sheer stress, and changes in
extracellular matrix composition.

# Production, deposition, or organization of collagen is impaired under the

influence of growth factors, cytokines, and matrix metalloproteinases with
resultant increased extracellular matrix deposition .
(Kougias and Nguyen et al., 2006).
Neointimal hyperplasia:
# Represents a chronic structural change in the blood vessel that leads to
formation of a thickened fibrocellular layer between the endothelium and
the inner elastic lamina of the arterial wall.

# Responsible for 20–50% of the clinical failures of all vascular interventions.

(Kougias and Nguyen et al., 2006).

Cellular and molecular mechanisms of neointimal hyperplasia:

# Neointimal hyperplasia after vascular injury involves three phases:
medial SMC proliferation (first wave), medial SMC migration into the
intima (second wave) and intimal SMC proliferation and extracellular
matrix production (third wave). (Lazaris and Salas et al., 2006).
Clinical strategy for restenosis:
Pharmacologic approach
1-Antiplatelet drugs: Low dose Aspirin has documented efficacy for
prevention of rethrombosis in the early phase of balloon angioplasty and
should be administered 2 h before the procedure . (Gorelick and Born et
al., 2005).

2-Anticoagulants: Heparin is important because:

(1) It reduces the risk of thrombosis .
(2) Heparin has anti-SMC proliferative activity.
(Gorelick and Born et al., 2005).

3-Essential fatty acids: Attenuate free radical generation and modify the
body’s inflammatory response to tissue injury (Ferns and Avades , 2000).

4-Gene therapy: Involves overexpression of genes that are considered

protective or blockade of genes that are involved in the pathogenesis of the
intimal hyperplasia achieved through the use of nucleic acids known as
antisense oligodeoxynucleotides (ODN). (Kougias and Nguyen et al.,
2006).
Endovascular strategy for restenosis:

Drug-eluting stent design principles:

Drug-eluting stents are composed of a three-dimensional complex.
The stent-based drug delivery system can be accomplished through
application of thin layers of a drug-polymer solution to the stent surface.

The key component of using any biopolymer is that the polymer is a

non inflammatory inert non thrombogenic component.

Unfortunately, without a polymer to aid in drug delivery, 40% of the

drug can be lost during stent placement, and after placement, the
remainder of the drug will completely elute in 1–2 weeks.

An alternative approach for drug delivery is direct application of the

drug to a bare stent or incorporation of the drug into microscopic
fenestration in the stent. This approach is currently being used for the
paclitaxel-eluting stents.
(Grube and Silber et al., 2003).
Drug eluting agents:
The basic function is to create an antiproliferative environment around
the stent in order to prevent luminal stenosis and neointimal hyperplasia.

The drug should have a reasonably long half-life of at least 4 weeks

postprocedure since this is the time during which the greatest endothelial
injury and reactivity to stent placement occurs
(Grube and Silber et al., 2003).
 SURGERY VERSUS ANGIOPLASTY IN
TREATMENT OF TIBIAL ARTERIES DISEASES
The technical success rate of angioplasty is often reported to be in the range
of 90%.

The initial hemodynamic success defined as an increase in the ABIs or PVRs

at the ankle for infrgenicular PTA.

Percutaneous transluminal angioplasty (PTA) has been proposed as a safe,

effective, less expensive alternative to lower extremity arterial bypass graft
surgery for treating limb-threatening ischemia and claudication. The
effectiveness of PTA in the treatment of tibial occlusive disease is well
established, with good long-term patency achieved.

Early success with PTA in the treatment of focal stenoses in the tibial
arteries led us to expand the indications for PTA to include longer, more distal
lesions with less favorable runoff, particularly in high-risk patients and those
whose surgical options are less promising.
(Perera and Lyden, 2007).
Medics Index Member Contribution

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