Contraindications to Peripheral Angioplasty
The provided evidence addresses coronary angioplasty contraindications rather than peripheral angioplasty, but the fundamental principles can be extrapolated to peripheral interventions with important modifications for the peripheral vascular context.
Absolute Contraindications
The following represent situations where peripheral angioplasty should not be performed:
No hemodynamically significant stenosis present - intervention is not indicated when there is no significant flow-limiting lesion 1
Absence of on-site vascular surgical backup - emergency surgical intervention is required in approximately 2.3% of peripheral angioplasty procedures for complications such as acute limb ischemia and hemorrhage 2
Diffuse disease without focal dilatable lesions - when extensive atherosclerosis is present throughout the vessel without discrete target lesions amenable to angioplasty, surgical revascularization is more appropriate 1
Unprotected critical inflow lesions - analogous to unprotected left main disease in coronary circulation, critical aortoiliac disease without collateral protection represents excessive risk 1
Relative Contraindications
These situations require careful risk-benefit assessment and may be appropriate in highly symptomatic patients:
Coagulation Abnormalities
Active coagulopathy or bleeding disorders increase the risk of serious hemorrhagic complications requiring transfusion (occurring in 22.4% of patients with vascular complications) 1, 3
Hypercoagulable states carry unacceptable risk of acute thrombotic occlusion of the dilated vessel 1
Patient-Specific Factors
Advanced age and female gender are independent predictors of peripheral vascular complications, with female patients showing particularly elevated risk 3, 4
Chronic renal failure is associated with increased morbidity due to contrast-induced nephropathy and prolonged hospitalization, with restenosis rates as high as 81% in dialysis patients 1
Pre-existing peripheral vascular disease increases periprocedural complication risk by 50% (multivariate odds ratio 1.5) 5
Lesion-Specific Factors
Chronic total occlusions >3 months old have very low anticipated success rates 1
Borderline stenotic lesions (<50-60% stenosis) should not be dilated due to risk of creating more severe restenotic lesions 1
Lesions exceeding 20 mm in length have significantly reduced success rates 1
Clinical Context Contraindications
Absence of clinical ischemia - intervention without documented symptoms or objective evidence of ischemia is not justified 1
Patient unable to provide informed consent or does not understand procedural risks, complications, and alternatives 1
Critical Pitfalls to Avoid
Do not proceed with angioplasty when the risk of acute vessel closure would result in limb-threatening ischemia without adequate collateral circulation - this parallels the coronary guideline regarding patients at risk for cardiogenic shock 1
Recognize that major complications (death, myocardial infarction, stroke, emergency revascularization) occur in 3.5% of peripheral angioplasty procedures overall, with amputation rates of 0.6% for claudication and 2.2% for critical limb ischemia 2