What is the Role of Translesional Pressure Gradient Measurement in Peripheral Intervention?

In this issue of the Journal of Invasive Cardiology Dr. Banerjee and colleagues evaluate the relationship of walking impairment, ankle-brachial index (ABI), and resting and hyperemic translesional gradients in patients with isolated superficial femoral artery (SFA) disease with no inflow or outflow lesions.¹ Although there are many articles regarding the use of translesional gradients to guide coronary intervention there are little data on the use of these to guide SFA intervention. The authors have shown a strong statistical correlation between translesional gradients, walking impairment, and resting and post-excercise ABIs in isolated SFA disease. Is it possible that translesional gradients will be used to guide peripheral interventional therapy?

Resting blood flow in leg vessels is substantially less than coronary or cerebral blood flow. Because of this, resting translesional gradients are typically less. In this paper, resting and hyperemic gradients were measured but one must question if hyperemic augmentation would be achieved with inflow or outflow disease. Severely calcific vessels may not dilate with adenosine or nitroglycerine and may not fully compress with external cuffs making the measurement of hyperemic gradients difficult. Three of the nineteen patients studied had less than 25% stenoses by quantitative angiography utilizing multiple angiographic views which should not result in hemodynamic gradients if this was a correct measure of the extent of stenosis. Should one consider intervening on an angiographically insignificant lesion because of translesional gradients?

The determination of when interventions should be performed and what are appropriate endpoints with intervention are complex decisions. The measurement of translesional gradients needs to be correlated with clinical outcomes to determine its ultimate utility in peripheral vascular interventions. If gradients correlate with ultimate outcomes then dissections without gradients may not need stenting, and less contrast may be needed for followup angiograhic evaluation lessening the risk of contrast induced nephropathy. In the coronary circulation decisions on whether or not to intervene and appropriate clinical endpoints correlate well with measurement of translesional gradients. Much more work is needed to establish if there is clinical utility in translesional pressure gradient measurement in peripheral interventions where gradients are less and not always apparent.

Reference

1. Banerjee S, Badhey N, Lichtenwalter C, et al. Relationship of walking impairment and ankle-brachial index assessments with peripheral arterial translesional pressure gradients. J Invasive Cardiol 2011;23:352–356.

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From the Vascular Laboratory, Cardiovascular Institute of the South, Houma, Louisiana.
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. There were no reported conflicts regarding the content herein.
Address for correspondence: Craig Walker, MD, Cardiovascular Institute of the South, Vascular Laboratory, 225 Dunn Street, Houma, LA 70360. Email: drcrwalker@aol.com