Potential complications of balloon angioplasty

Clinical History

Dissection after PTA and vasospasm

Imaging Findings

Patient presented with recent onset of left-sided calf claudication after a short walking distance of 150 m (stage II b Fontaine). Angiography revealed as a single lesion a 4 cm long tight stenosis of the left popliteal artery with no additional significant lesions (Fig. 1). Ultrasound was performed to exclude cystic medial degeneration which is typically located in that position and should be excluded especially if a single lesion is present. Also a popliteal entrapment syndrome was excluded. After antegrade puncture of the left common femoral artery, the lesion was passed by catheter and a coated guidewire. Once the lesion was passed, the guidewire was exchanged for a conventional 0.035 in guidewire with a curved tip. Over the wire a 5 mm wide 4 cm long balloon catheter was inserted and PTA of the lesion was performed for 45 seconds. After PTA, a proximal dissection of the popliteal artery was seen. In additon, narrowing of distal popliteal artery at the level of the wire tip was seen (Fig. 2 a).

Discussion

Both findings are frequent and typical sequelae of balloon angioplasty. In this location, first measurement to treat dissection is prolonged dilation with low pressure dilation over 4 to 5 minutes. This technique is helpful in sealing many dissections (Fig. 2 b,c) If not and flow is high, prolonged heparinization should be the treatment of choice. Stenting is only indicated especially in the popliteal artery if no other option remains to keep the artery open. Vasospasm is frequently found in younger patients and may be much more dramatic as in our case. First step is oral application of nifedipine and additional heparin application. If this does not help, intravascular appliction of local anesthetics, nitroglycerine or nitroprusside is indicated. To avoid vasospasm especially in young patients, prophylactic oral application of nifedipine prior to the procedure is helpful as well as to avoid use of curved conventional guidewires in small arteries which can irritate the vascular wall. The phenomenon is less pronounced with coated guidewires.

Differential Diagnosis List

Final Diagnosis

Prolonged dilation and nifedipine to treat dissection and vasospasm

URL:	https://eurorad.org/case/494
DOI:	10.1594/EURORAD/CASE.494
ISSN:	1563-4086