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Commentary
When is Smaller Better?
August 2009
Vascular complications during endovascular intervention remain an important cause of the morbidity and mortality associated with the procedure. Risk factors for vascular complications include older age, location of the arteriotomy site and the size of the arterial sheath.1,2 The ability to reduce the size of the access sheath and still allow insertion of vascular devices is therefore an important aspect of endovascular intervention. While numerous endovascular devices have emerged for use for infrapopliteal intervention, balloon angioplasty remains the mainstay of therapy.3 Angioplasty balloons are now available in lengths of up to 200 mm, making angioplasty even more time efficient. Most operators in the United States use a 6 Fr sheath, either in an antegrade or retrograde (contralateral) approach, to perform infrapopliteal intervention.
Infrapopliteal artery intervention is most commonly performed for limb salvage in the setting of chronic limb ischmia (CLI). The goals of endovascular intervention for CLI are to establish direct in-line flow to the ischemic zone. A recent meta-analysis of balloon angioplasty for CLI including thirty studies from 1990 through 2006 found a technical success rate of 89% and a limb salvage rate of 93% at 1 month and 82% at 3 years.4 These limb salvage rates compare favorably to bypass surgery.5 Given the reduced morbidity and mortality, shorter hospital stay and ability to use local anesthesia, many vascular specialists use endovascular intervention as the initial treatment approach for CLI.
In this issue of the Journal of Invasive Cardiology, Kawarada et al describe the use of a novel 3 Fr sheath (Super Sheath, Medikit Company, Ltd. Tokyo, Japan) to perform infrapopliteal intervention in 11 patients with critical limb ischemia. The 3 Fr sheath was placed within the common femoral or proximal superficial femoral artery in an antegrade manner. Using a 0.014 inch guidewire and a monorail balloon available in Japan (Kaneka Medix Corporation, Osaka, Japan) and ranging in size from 1.5–4.0 mm, balloon angioplasty of the popliteal and infrapopliteal vessels was performed. Balloon angioplasty was performed on the popliteal artery, the infrapopliteal arteries and as distal as the plantar artery. Hemostasis was achieved immediately following the procedure using manual compression applied for 5 minutes, followed by a compressive dressing. The authors achieved technical success (residual stenosis From the David Geffen School of Medicine at UCLA, Los Angeles County/Harbor UCLA Medical Center, Torrance, California.
The author reports no conflicts of interest regarding the content herein.
Address for correspondence: David M. Shavelle, MD, FACC, FSCAI, Associate Clinical Professor, David Geffen School of Medicine at UCLA, Director, Interventional Cardiology Fellowship, Director, Interventional Cardiology, Los Angeles County/Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509. E-mail: dshavelle@hotmail.com
1. Sherev DA, Shaw RE, Brent BN. Angiographic predictors of femoral access site complications: Implication for planned percutaneous coronary intervention. Catheter Cardiovasc Interv 2005;65:196–202.
2. Chandrasekar B, Doucet S, Bilodeau L, et al. Complications of cardiac catheterization in the current era: A single-center experience. Catheter Cardiovasc Interv 2001;52:289–295.
3. Menard MT, Belkin M. Infrapopliteal intervention for the treatment of the claudicant. Semin Vasc Surg 2007;20:42–53.
4. Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975–981.
5. Adam DJ, Beard JD, Cleveland T, et al. for the BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet 2005;366:1925–1934.
