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Angioplasty
Brandt C. Wible, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Percutaneous transluminal angioplasty (PTA): Inflation of catheter-mounted balloon within narrowed vascular structure to enlarge luminal diameter, improve flow hemodynamics
              • Arterial angioplasty: Primary mechanism is controlled fracture of obstructing atherosclerotic plaque
                • Desquamation of endothelial cells
                • Causes fissures in plaque/intima; stretches media
                  • Virtually no compression of plaque itself
              • Venous angioplasty: PTA of stenotic venous lumen
                • Stretches entire vein wall, usually without fissures
                • Often requires high-pressure balloon
              • Stent associated: PTA often performed in conjunction with stenting
                • Predilation PTA of stenosis, allowing stent advancement into position
                • Postdeployment PTA, maximally distending & securing stent
              • Post angioplasty: In weeks following PTA, reendothelialization of intima occurs; vessel remodels
                • Post-PTA restenosis due to prolific neointimal hyperplasia &/or major vascular remodeling (e.g., recoil); largely an inflammatory response
            • Angioplasty catheter designs
              • Over-the-wire (OTW): Central lumen for guidewire access/contrast injection, small parallel lumen within catheter for balloon inflation/deflation
                • Traditional angioplasty balloon catheter design
                • Guidewire in central lumen improves catheter tracking & pushability
                • Contrast can be injected through catheter
              • Rapid exchange (monorail): Guidewire passes through balloon, exits catheter proximal to balloon, runs outside catheter shaft
                • Increasingly popular angioplasty catheter
                • Exchange length guidewires unnecessary
                • Balloon typically has lower profile
                • Rapid balloon inflation/deflation times
                • Often used with guide-catheter/sheath to minimize following disadvantages
                  • Unable to inject contrast through catheter
                  • Poorer trackability/pushability than OTW
            • Various angioplasty technologies/techniques
              • Conventional, a.k.a. plain old balloon angioplasty (POBA): Balloon inflation within narrowed lumen
                • Outward force (measured in atmospheres) exerted by balloon against obstructing lesion/stenosis
                • Degree of force depends on
                  • Diameter, compliance (elasticity), inflation pressure, and length of angioplasty balloon
                  • Severity and morphology of stenosis
              • Cutting balloon angioplasty: 3-4 atherotomes (microsurgical blades) fixed longitudinally on surface of noncompliant balloon
                • Atherotomes expand radially, delivering longitudinal incisions in plaque & vessel
                  • Theoretically reduces vessel stretch/injury by scoring plaque vs. uncontrolled disruption
                  • Randomized trial of 1,385 coronary lesions: No clinical or angiographic difference between cutting & standard PTA at 6-month follow-up
                  • Some small studies suggest lower restenosis rates
                  • Generally infrequently used for arterial lesions
                  • Most frequently used for PTA of venous stenoses
              • Scoring balloon angioplasty: Balloon surrounded by wire "cage" for focally concentrated dilatation
                • AngioSculpt scoring balloon (AngioScore): Semicompliant balloon encircled by 3-4 nitinol spiral struts
                  • Balloon inflation focuses radial force along edges of struts, scoring plaque circumferentially
                  • Similar technology to cutting balloon angioplasty; wires rather than blades
                • VascuTrak PTA balloon (Bard Peripheral Vascular): 2 flexible longitudinal wires externally parallel semicompliant balloon
                  • Flexible wires score plaque in tortuous vessels
                  • 0.014"/0.018" rapid exchange system
                  • Balloon lengths from 20-300 mm
              • Cryoplasty: Combines angioplasty with cold energy to treat obstructive atherosclerotic plaque
                • PolarCath peripheral dilation catheter (Boston Scientific)
                • Liquid nitrous oxide used to inflate balloon while lowering its surface temperature to -10°C
                  • Theoretically causes altered plaque response, decreased elastic recoil, cellular apoptosis
                • Recent trials indicate cryoplasty does not offer outcomes superior to balloon angioplasty
                  • Unfavorable cost-benefit
                  • Possibly higher restenosis rates
              • Drug-eluting balloon angioplasty: Balloon coated with medication (e.g., paclitaxel)
                • Delivers antiproliferative drug to vessel surface
                  • Local drug application to vessel surface to prevent restenosis without placing stent
                  • High drug concentration reduces neointimal proliferation even with short time exposure
                • Investigational device with ongoing trials

          PREPROCEDURE

          • Indications

            • Contraindications

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Equipment Preparation

                    • Procedure Steps

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                              2. Diehm NA et al: Drug eluting balloons. Tech Vasc Interv Radiol. 13(1):59-63, 2010
                              3. Banerjee S et al: Atheroemboli during peripheral arterial interventions. J Invasive Cardiol. 21(12):632-3, 2009
                              4. Bosiers M et al: Use of the AngioSculpt scoring balloon for infrapopliteal lesions in patients with critical limb ischemia: 1-year outcome. Vascular. 17(1):29-35, 2009
                              5. Conrad MF et al: Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg. 50(4):799-805, 2009
                              6. Das TS et al: Primary cryoplasty therapy provides durable support for limb salvage in critical limb ischemia patients with infrapopliteal lesions: 12-month follow-up results from the BTK Chill Trial. J Endovasc Ther. 16(2 Suppl 2):II19-30, 2009
                              7. Laird JR et al: The role for cryoplasty in the treatment of infrainguinal artery disease: case studies. J Endovasc Ther. 16(2 Suppl 2):II116-28, 2009
                              8. Shammas NW: Restenosis after lower extremity interventions: current status and future directions. J Endovasc Ther. 16 Suppl 1:I170-82, 2009
                              9. Siablis D: Atheroembolization and peripheral vascular interventions: the evidence is mounting. J Endovasc Ther. 16(2):203-5, 2009
                              10. Wilson AM et al: Randomized controlled trial of aspirin and clopidogrel versus aspirin and placebo on markers of smooth muscle proliferation before and after peripheral angioplasty. J Vasc Surg. 50(4):861-9, 2009
                              11. Bosiers M et al: Present and future of endovascular SFA treatment: stents, stent-grafts, drug coated balloons and drug coated stents. J Cardiovasc Surg (Torino). 49(2):159-65, 2008
                              12. Fonseca A et al: Intravascular ultrasound assessment of the novel AngioSculpt scoring balloon catheter for the treatment of complex coronary lesions. J Invasive Cardiol. 20(1):21-7, 2008
                              13. Werk M et al: Inhibition of restenosis in femoropopliteal arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation. 2008 Sep 23;118(13):1358-65. Epub 2008 Sep 8. Erratum in: Circulation. 118(16):e670, 2008
                              14. Scheinert D et al: Results of the multicenter first-in-man study of a novel scoring balloon catheter for the treatment of infra-popliteal peripheral arterial disease. Catheter Cardiovasc Interv. 70(7):1034-9, 2007
                              15. Laird JR et al: Cryoplasty for the treatment of femoropopliteal arterial disease: extended follow-up results. J Endovasc Ther. 13 Suppl 2:II52-9, 2006
                              Related Anatomy
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                              Related Differential Diagnoses
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Procedure

                                  • Post Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Definitions

                                        • Percutaneous transluminal angioplasty (PTA): Inflation of catheter-mounted balloon within narrowed vascular structure to enlarge luminal diameter, improve flow hemodynamics
                                          • Arterial angioplasty: Primary mechanism is controlled fracture of obstructing atherosclerotic plaque
                                            • Desquamation of endothelial cells
                                            • Causes fissures in plaque/intima; stretches media
                                              • Virtually no compression of plaque itself
                                          • Venous angioplasty: PTA of stenotic venous lumen
                                            • Stretches entire vein wall, usually without fissures
                                            • Often requires high-pressure balloon
                                          • Stent associated: PTA often performed in conjunction with stenting
                                            • Predilation PTA of stenosis, allowing stent advancement into position
                                            • Postdeployment PTA, maximally distending & securing stent
                                          • Post angioplasty: In weeks following PTA, reendothelialization of intima occurs; vessel remodels
                                            • Post-PTA restenosis due to prolific neointimal hyperplasia &/or major vascular remodeling (e.g., recoil); largely an inflammatory response
                                        • Angioplasty catheter designs
                                          • Over-the-wire (OTW): Central lumen for guidewire access/contrast injection, small parallel lumen within catheter for balloon inflation/deflation
                                            • Traditional angioplasty balloon catheter design
                                            • Guidewire in central lumen improves catheter tracking & pushability
                                            • Contrast can be injected through catheter
                                          • Rapid exchange (monorail): Guidewire passes through balloon, exits catheter proximal to balloon, runs outside catheter shaft
                                            • Increasingly popular angioplasty catheter
                                            • Exchange length guidewires unnecessary
                                            • Balloon typically has lower profile
                                            • Rapid balloon inflation/deflation times
                                            • Often used with guide-catheter/sheath to minimize following disadvantages
                                              • Unable to inject contrast through catheter
                                              • Poorer trackability/pushability than OTW
                                        • Various angioplasty technologies/techniques
                                          • Conventional, a.k.a. plain old balloon angioplasty (POBA): Balloon inflation within narrowed lumen
                                            • Outward force (measured in atmospheres) exerted by balloon against obstructing lesion/stenosis
                                            • Degree of force depends on
                                              • Diameter, compliance (elasticity), inflation pressure, and length of angioplasty balloon
                                              • Severity and morphology of stenosis
                                          • Cutting balloon angioplasty: 3-4 atherotomes (microsurgical blades) fixed longitudinally on surface of noncompliant balloon
                                            • Atherotomes expand radially, delivering longitudinal incisions in plaque & vessel
                                              • Theoretically reduces vessel stretch/injury by scoring plaque vs. uncontrolled disruption
                                              • Randomized trial of 1,385 coronary lesions: No clinical or angiographic difference between cutting & standard PTA at 6-month follow-up
                                              • Some small studies suggest lower restenosis rates
                                              • Generally infrequently used for arterial lesions
                                              • Most frequently used for PTA of venous stenoses
                                          • Scoring balloon angioplasty: Balloon surrounded by wire "cage" for focally concentrated dilatation
                                            • AngioSculpt scoring balloon (AngioScore): Semicompliant balloon encircled by 3-4 nitinol spiral struts
                                              • Balloon inflation focuses radial force along edges of struts, scoring plaque circumferentially
                                              • Similar technology to cutting balloon angioplasty; wires rather than blades
                                            • VascuTrak PTA balloon (Bard Peripheral Vascular): 2 flexible longitudinal wires externally parallel semicompliant balloon
                                              • Flexible wires score plaque in tortuous vessels
                                              • 0.014"/0.018" rapid exchange system
                                              • Balloon lengths from 20-300 mm
                                          • Cryoplasty: Combines angioplasty with cold energy to treat obstructive atherosclerotic plaque
                                            • PolarCath peripheral dilation catheter (Boston Scientific)
                                            • Liquid nitrous oxide used to inflate balloon while lowering its surface temperature to -10°C
                                              • Theoretically causes altered plaque response, decreased elastic recoil, cellular apoptosis
                                            • Recent trials indicate cryoplasty does not offer outcomes superior to balloon angioplasty
                                              • Unfavorable cost-benefit
                                              • Possibly higher restenosis rates
                                          • Drug-eluting balloon angioplasty: Balloon coated with medication (e.g., paclitaxel)
                                            • Delivers antiproliferative drug to vessel surface
                                              • Local drug application to vessel surface to prevent restenosis without placing stent
                                              • High drug concentration reduces neointimal proliferation even with short time exposure
                                            • Investigational device with ongoing trials

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Getting Started

                                            PROCEDURE

                                            • Patient Position/Location

                                              • Equipment Preparation

                                                • Procedure Steps

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Things to Do

                                                      OUTCOMES

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                                                          2. Diehm NA et al: Drug eluting balloons. Tech Vasc Interv Radiol. 13(1):59-63, 2010
                                                          3. Banerjee S et al: Atheroemboli during peripheral arterial interventions. J Invasive Cardiol. 21(12):632-3, 2009
                                                          4. Bosiers M et al: Use of the AngioSculpt scoring balloon for infrapopliteal lesions in patients with critical limb ischemia: 1-year outcome. Vascular. 17(1):29-35, 2009
                                                          5. Conrad MF et al: Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg. 50(4):799-805, 2009
                                                          6. Das TS et al: Primary cryoplasty therapy provides durable support for limb salvage in critical limb ischemia patients with infrapopliteal lesions: 12-month follow-up results from the BTK Chill Trial. J Endovasc Ther. 16(2 Suppl 2):II19-30, 2009
                                                          7. Laird JR et al: The role for cryoplasty in the treatment of infrainguinal artery disease: case studies. J Endovasc Ther. 16(2 Suppl 2):II116-28, 2009
                                                          8. Shammas NW: Restenosis after lower extremity interventions: current status and future directions. J Endovasc Ther. 16 Suppl 1:I170-82, 2009
                                                          9. Siablis D: Atheroembolization and peripheral vascular interventions: the evidence is mounting. J Endovasc Ther. 16(2):203-5, 2009
                                                          10. Wilson AM et al: Randomized controlled trial of aspirin and clopidogrel versus aspirin and placebo on markers of smooth muscle proliferation before and after peripheral angioplasty. J Vasc Surg. 50(4):861-9, 2009
                                                          11. Bosiers M et al: Present and future of endovascular SFA treatment: stents, stent-grafts, drug coated balloons and drug coated stents. J Cardiovasc Surg (Torino). 49(2):159-65, 2008
                                                          12. Fonseca A et al: Intravascular ultrasound assessment of the novel AngioSculpt scoring balloon catheter for the treatment of complex coronary lesions. J Invasive Cardiol. 20(1):21-7, 2008
                                                          13. Werk M et al: Inhibition of restenosis in femoropopliteal arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation. 2008 Sep 23;118(13):1358-65. Epub 2008 Sep 8. Erratum in: Circulation. 118(16):e670, 2008
                                                          14. Scheinert D et al: Results of the multicenter first-in-man study of a novel scoring balloon catheter for the treatment of infra-popliteal peripheral arterial disease. Catheter Cardiovasc Interv. 70(7):1034-9, 2007
                                                          15. Laird JR et al: Cryoplasty for the treatment of femoropopliteal arterial disease: extended follow-up results. J Endovasc Ther. 13 Suppl 2:II52-9, 2006