When is transluminal angioplasty recommended for patients with arterial stenosis or occlusion?

Indications for Transluminal Angioplasty in Arterial Stenosis or Occlusion

Transluminal angioplasty is recommended for patients with significant arterial stenosis (>60%) who have objective evidence of myocardial ischemia or disabling symptoms despite medical therapy, particularly when lesions have favorable morphology for successful dilation and patients are at low to moderate risk for procedural complications. 1

Patient Selection Criteria

Class I Indications (Strong Recommendation)

• Symptomatic patients with:

  • Significant lesions in major epicardial arteries
  • Evidence of myocardial ischemia while on medical therapy
  • Angina pectoris inadequately responsive to medical therapy
  • Intolerance to medical therapy due to side effects 1

• Asymptomatic or mildly symptomatic patients who:

  • Have a large area of viable myocardium at risk
  • Show severe myocardial ischemia during stress testing
  • Have been resuscitated from cardiac arrest or sustained ventricular tachycardia
  • Are undergoing high-risk noncardiac surgery with evidence of ischemia 1

Anatomical Considerations

• Favorable lesion characteristics:

  • Type A or B lesions with high likelihood of successful dilation
  • Lesions that would provide relief to all major regions of ischemia 1

• Location-specific outcomes:

  • Common iliac artery PTA has superior outcomes (87% 1-year patency) compared to external iliac (56%) 2
  • Infrainguinal PTAs (femoral, popliteal, tibial) show significantly poorer outcomes (<15% 1-year patency) 2
  • Subclavian artery occlusions can be successfully treated, though long-term patency may be <50% 3

Contraindications

Absolute Contraindications

1. No significant obstructing lesion present
2. Multivessel disease with severe diffuse atherosclerosis where bypass surgery would be more efficacious
3. Unprotected left main coronary artery obstruction >50%
4. No formal cardiac surgical program within the institution 1

Relative Contraindications

1. Presence of coagulopathy
2. No clinical evidence of spontaneous or inducible myocardial ischemia
3. High risk of cardiogenic shock in multivessel angioplasty
4. Low anticipated success rate (e.g., chronic total occlusions >3 months old, lesions >20mm)
5. Borderline stenotic lesions (<60%) without evidence of ischemia 1

Risk Assessment

The decision to perform transluminal angioplasty must balance:

• Potential benefits:

  • Relief of ischemia
  • Improved functional capacity
  • Reduced symptoms

• Against risks:

  • Procedural complications (arterial/venous obstructions, vessel perforations, bleeding)
  • Early vessel closure
  • Restenosis 1

Risk stratification should consider:

• Patient's symptomatic state
• General medical condition
• Size of viable myocardium at risk
• Lesion characteristics 1

Special Considerations

Limb-Threatening Ischemia

For patients with limb-threatening ischemia, location significantly impacts outcomes:

• Common iliac PTA is justified in most feasible cases
• Infrainguinal PTA should not be considered as primary treatment except in unusual circumstances, as bypass grafting provides superior patency rates 2

Intermittent Claudication

PTA of infrapopliteal arteries for intermittent claudication:

• Can achieve good acute clinical results (improvement in walking distance and ankle-brachial index)
• Shows encouraging long-term patency rates (66.3% primary patency at 12 months)
• Has relatively low complication rates (5.8%) 4

Acute Cerebral Artery Occlusion

Direct PTA may be considered for acute middle cerebral artery occlusion when:

• Early ischemic findings are present on initial CT scans
• Lenticulostriate arteries are involved
• Superselective angiography shows large embolus or high-grade stenosis 5

Common Pitfalls

1. Inappropriate patient selection: Performing PTA on patients with borderline lesions (<60% stenosis) without evidence of ischemia can lead to worse stenosis after the procedure 1

2. Location-based failures: Not accounting for anatomical location when deciding on PTA vs. bypass grafting, particularly for infrainguinal disease 2

3. Inadequate follow-up: Secondary deterioration can occur, making morphologic surveillance crucial for early detection of restenosis 6

4. Underestimating complexity: Not recognizing when multivessel disease requires consideration of each lesion in context of all others present 1

Transluminal angioplasty should be performed with careful consideration of these factors to maximize benefits while minimizing risks for patients with arterial stenosis or occlusion.