Lower Limb Angioplasty
Chronic Limb-Threatening Ischaemia (CLTI) is an advanced form of peripheral arterial disease. It is characterised by chronic ischaemic rest pain and/or tissue loss (ulcers or gangrene) affecting one or both legs. Severe atherosclerotic blockage in the arteries of the lower extremities result in markedly reduced blood flow within the lower limb. Its chronicity sets it apart from acute limb ischaemia which is a rapid onset decrease in/loss of blood flow affecting the lower limb.
The failure of conservative measures and the onset of debilitating symptoms are indications for surgical intervention. Treatment priority is to preserve the limb. This may be achieved using minimally invasive endovascular therapy or ‘open’ surgery. Endovascular treatments include:
- Angioplasty: balloon dilatation of the occluded segment of the artery
- Stents: metal mesh tubes left in place following balloon angioplasty
- Atherectomy mechanical debulking of atheroma with a cutting blade or laser
Open techniques remain in use for selected patients, and include endarterectomy (for common femoral artery disease), and bypass grafting (for distal or diffuse disease), which involves bypassing the blocked segment with either an autologous vein or a synthetic graft.
Operator Considerations
Indications: CLTI
Contraindications: unsalvageable limb
Planning: ultrasound duplex examination and/or CT/MRI angiography
Preparation: antiplatelet therapy should be continued. Other anticoagulants e.g., NOACs and DOACs should be stopped in accordance with local protocols.
Duration: depends on the number of “levels” requiring revascularisation (i.e. iliac, femoral, tibial), complexity (i.e. stenosis vs. occlusion). Supra-popliteal work typically takes 1- 2 hours, infrapopliteal work, a minimum of 3-4 hours.
Position: supine
Access: groin (same leg or contralateral leg to work “up and over” the aortic bifurcation)
Technique: percutaneous access, cross atherosclerotic lesions with a guidewire and open them with angioplasty/stents/atherectomy
Complications: distal embolisation, thrombosis, vessel dissection, contrast nephropathy, groin bleeding from access site
Post-procedure instructions: 4 hours bed-rest, usually with first 2 hours flat depending on use of closure device or manual compression to achieve groin haemostasis