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Cutting Balloon Percutaneous Transluminal Angioplasty for Salvage of Lower Limb Arterial Bypass Grafts: Feasibility¹

¹ From the Department of Diagnostic Radiology, St George’s Hospital, London, England. From the 2000 RSNA scientific assembly. Received April 16, 2001; revision requested June 2; revision received August 15; accepted September 7. Address correspondence to C.E., Department of Radiology, Klinikum Rechts der Isar, Ismaninger Strasse 22, D-81675 Munich, Germany (e-mail: cengelke@hotmail.com).

View larger version (53K): [in a new window]   Figure 1. Cutting balloon function. Left: Microsurgical blades are covered inside balloon folds in the deflated state (profile view). Right: During inflation, the microtomes are exposed and pressed into adjacent structures. (Image courtesy of IVT Europe, Lisnenan, Letterkenny, County Donegal, Ireland.)

View larger version (93K): [in a new window]   Figure 2. Posteroanterior digital subtraction angiograms of a common femoral to above-knee popliteal artery PTFE bypass graft (*). Left: Image shows a distal bypass graft stenosis (arrowhead). Middle: Image shows the result after cutting balloon PTA with a 4.0-mm-diameter balloon with partial dilation of the stenosis (arrowhead). Right: Subsequent image shows the final result after subsequent conventional PTA with a 6.0-mm-diameter balloon that was 20 mm long (arrowhead). Lesion was successfully treated, and restenosis did not occur during a 9-month follow-up.

View larger version (77K): [in a new window]   Figure 3. Posteroanterior unsubtracted angiograms show a femoropopliteal vein bypass graft (*) with distal anastomosis below the knee. Far left: Image shows a distal anastomotic stenosis (arrowhead). Left middle: Image shows the result of initial conventional PTA with 6-mm-diameter balloon that failed to dilate the rigid stenosis (arrowhead) of neointimal hyperplasia. Right middle: Image shows the result after subsequent cutting balloon PTA with 4.0-mm-diameter balloon that achieved partial dilatation of the resistant stenosis (arrowhead). Far right: Image shows the final result after subsequent conventional PTA that achieved normal vessel diameter (arrowhead), which was maintained during a follow-up of 4 months.

View larger version (117K): [in a new window]   Figure 4. Posteroanterior digital subtraction angiograms show a femorodistal PTFE vein composite bypass graft (*) with venous graft anastomosis to the posterior tibial artery. Far left: Image shows an anastomotic (arrow) and postanastomotic (arrowheads) stenosis (image composed from two data acquisitions). Left middle: Image shows the result after conventional PTA of combined anastomotic and postanastomotic stenosis with a 3.0-mm-diameter balloon that was 20 mm long. The anastomotic stenosis (arrow) did not respond (magnified image). Right middle: Image shows the result after subsequent anastomotic cutting balloon PTA with a 2.5-mm-diameter device and final subsequent conventional PTA and subsequent conventional PTA with a 3.0-mm-diameter balloon that was 20 mm long, with satisfactory anastomotic (arrow) and distal (arrowheads) results, which were maintained to date (3 months follow-up). Far right: Magnification of image at right middle.

View larger version (112K): [in a new window]   Figure 5. Posteroanterior digital subtraction angiograms of an aortobifemoral PTFE bypass graft (*). Left: Image shows a stenosis at the left distal deep femoral artery anastomosis (arrowhead). Right: Magnified image shows the result after cutting balloon PTA and subsequent conventional PTA (arrowhead). The procedure was performed from a right distal graft limb access (6-F introducer sheath) without aid of a crossover sheath. This lesion developed restenosis after 5 months, and the restenosis was successfully treated with repeat cutting balloon PTA.

View larger version (17K): [in a new window]   Figure 6. (a) Cumulative primary and secondary local patency (Kaplan-Meier) rates (in percentages) at the cutting balloon PTA sites. (b) Cumulative primary and secondary graft patency (Kaplan-Meier) rates (in percentages) after cutting balloon PTA. Dotted lines = primary patency rates, solid lines = secondary patency rates.