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Endovascular
Therapy
PRINCIPLES OF
PERIPHERAL
I N T E RV E N T I O N S

Alan B. Lumsden, MD
Peter H. Lin, MD
Ruth L. Bush, MD
Changyi Chen, MD, PhD
Baylor College of Medicine, Houston, Texas

LLBC: “fm” — 2005/10/29 — 16:54 — page i — #1

© 2006 by Blackwell Publishing
Blackwell Futura is an imprint of Blackwell Publishing
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
All rights reserved. No part of this publication may be reproduced in any form or by any
electronic or mechanical means, including information storage and retrieval systems, without
permission in writing from the publisher, except by a reviewer who may quote brief passages
in a review.
First published 2006
ISBN-13: 978-1-4051-24232
ISBN-10: 1-4051-24237
Library of Congress Cataloging-in-Publication Data

Endovascular therapy : principles of peripheral interventions/edited

by Alan B. Lumsden . . . [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-2423-2 (hardcover : alk. paper)
ISBN-10: 1-4051-2423-7 (hardcover : alk. paper)
1. Blood-vessels–Endoscopic surgery. 2. Peripheral vascular diseases–Endoscopic surgery.
[DNLM: 1. Arterial Occlusive Diseases–surgery. 2. Peripheral Vascular Diseases–surgery.
3. Angioplasty–methods. 4. Angioscopy–methods. 5. Stents. WG 500 E5665 2006] I. Lumsden,
Alan B.

RD598.5.E56 2006
617.4
130597–dc22
2005026041

A catalogue record for this title is available from the British Library
Acquisitions: Steve Korn
Production: Simone Dudziak
Set in 9.5/12pt Palatino
by Newgen Imaging Systems (P) Ltd, Chennai, India
Printed and bound by Replika Press PVT. Ltd, India
For further information on Blackwell Publishing, visit our website:
www.blackwellcardiology.com

The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry
policy, and which has been manufactured from pulp processed using acid-free and elementary
chlorine-free practices. Furthermore, the publisher ensures that the text paper and cover board
used have met acceptable environmental accreditation standards.
Notice: The indications and dosages of all drugs in this book have been recommended in the
medical literature and conform to the practices of the general community. The medications
described do not necessarily have specific approval by the Food and Drug Administration for
use in the diseases and dosages for which they are recommended. The package insert for each
drug should be consulted for use and dosage as approved by the FDA. Because standards for
usage change, it is advisable to keep abreast of revised recommendations, particularly those
concerning new drugs.

LLBC: “fm” — 2005/10/29 — 16:54 — page ii — #2

Contents

Editors, v
List of Contributors, vii
Foreword, xi
Preface, xiii
Acknowledgments, xv

1 General principles of endovascular therapy, 1

Imran Mohiuddin, Panagiotis Kougias, Ross Milner

2 Basic science of endovascular therapy, 20

Panagiotis Kougias, Liz Nguyen, Changyi Chen

3 Pharmacotherapy in endovascular interventions, 38

Leila Mureebe, Colleen M. Johnson, Changyi Chen

4 Complications of endovascular therapy, 53

Gordon M. Riha, Changyi Chen, Ruth L. Bush

5 Carotid bifurcation disease, 68

Wei Zhou, Ruth L. Bush, Peter H. Lin, Alan B. Lumsden

6 Supra-aortic trunk and upper extremity arterial disease, 88

Imran Mohiuddin, Eric J. Silberfein, Eric Peden

7 Thoracic aortic disease, 103

Andy C. Chiou, Kristen L. Biggs, Peter H. Lin

8 Abdominal aortic aneurysm, 121

W. Anthony Lee, Daniel J. Martin, Imran Mohiuddin

9 Mesenteric artery occlusive disease, 139

Panagiotis Kougias, Mitchell Cox, Peter H. Lin

10 Renal artery occlusive disease, 154

Peter H. Lin, Rakesh Safaya, W. Todd Bohannon

11 Aortoiliac occlusive disease, 170

Eric Peden, Ruth L. Bush, Alan B. Lumsden

iii

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iv Contents

12 Lower extremity arterial disease, 186

Wei Zhou, Marlon A. Guerrero, Alan B. Lumsden
13 Arteriovenous graft interventions, 206
Joseph J. Naoum, Wei Zhou, Eric Peden
14 Venous insufficiency and varicose veins, 221
Panagiotis Kougias, Patrick E. Duffy, E. John Harris, Jr
15 Ileofemoral deep venous thrombosis, 239
James P. Gregg, Esteban A. Henao, Alan B. Lumsden
16 Vascular trauma, 252
Ulises Baltazar, Esteban A. Henao, W. Todd Bohannon, Michael B. Silva Jr
17 Endovascular devices in peripheral interventions, 268
Russell Lam, Mai Pham, Rakesh Safaya
Index, 283

Colour plates are found between pp. 80–81

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Editors

Alan B. Lumsden, MD Professor of Surgery; and Chief, Division of Vascular

Surgery and Endovascular Therapy, Michael E. DeBakey Department of
Surgery, Baylor College of Medicine Houston, Texas

Peter H. Lin, MD Associate Professor of Surgery, Chief of Vascular Surgery,

Michael E. DeBakey Veterans Affairs Medical Center, Division of Vascular Sur-
gery and Endovascular Therapy, Michael E. DeBakey Department of Surgery,
Baylor College of Medicine Houston, Texas

Ruth L. Bush, MD Assistant Professor of Surgery; and Director, Vascular

Surgery Fellowship Program, Division of Vascular Surgery and Endovascu-
lar Therapy, Michael E. DeBakey Department of Surgery, Baylor College of
Medicine Houston, Texas

Changyi Chen, MD, PhD Professor of Surgery & Molecular and Cellular
Biology; and Director, Molecular Surgeon Research Center, Vice Chairman,
Surgical Research, Division of Vascular Surgery and Endovascular Therapy,
Michael E. DeBakey Department of Surgery, Baylor College of Medicine
Houston, Texas

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LLBC: “fm” — 2005/10/29 — 16:54 — page vi — #6
List of Contributors

Ulises Baltazar, MD Patrick E. Duffy, MD

Division of Vascular Surgery Division of Vascular Surgery and Endovascular
Department of Surgery Therapy
East Tennessee State University Michael E. DeBakey Department of Surgery
Johnson City, Tennessee Baylor College of Medicine
Houston, Texas
Kristen L. Biggs, MD
Section of Vascular Surgery James P. Gregg, MD
Department of Surgery Division of Vascular Surgery and Endovascular
Wilford Hall USAF Medical Center Therapy
Lackland Air Force Base, Texas Michael E. DeBakey Department of Surgery
Baylor College of Medicine
W. Todd Bohannon, MD Houston, Texas
Division of Vascular Surgery
Department of Surgery Marlon A. Guerrero, MD
Scott & White Hospital and Clinic Division of Vascular Surgery and Endovascular
Texas A & M University Health Science Therapy
Center Michael E. DeBakey Department of Surgery
Temple, Texas Baylor College of Medicine
Houston, Texas
Ruth L. Bush, MD
Division of Vascular Surgery and Endovascular E. John Harris, Jr., MD
Therapy Division of Vascular Surgery
Michael E. DeBakey Department of Surgery Department of Surgery
Baylor College of Medicine Stanford University School of Medicine
Houston, Texas Stanford, California

Changyi Chen, MD, PhD Esteban A. Henao, MD

Division of Vascular Surgery and Endovascular Division of Vascular Surgery and Endovascular
Therapy Therapy
Michael E. DeBakey Department of Surgery Michael E. DeBakey Department of Surgery
Baylor College of Medicine Baylor College of Medicine
Houston, Texas Houston, Texas

Andy C. Chiou, MD, MPH Colleen M. Johnson, MD

Section of Endovascular Surgery Division of Vascular Surgery
Department of Surgery University of Missouri
University of Illinois College of Medicine Health Sciences Center
Peoria, Illinois Columbia, Missouri

Mitchell Cox, MD Panagiotis Kougias, MD

Uniformed Services University of the Health Division of Vascular Surgery and Endovascular
Sciences Therapy
Vascular Surgery Clinic Michael E. DeBakey Department of Surgery
Walter Reed Army Medical Center Baylor College of Medicine
Washington, DC Houston, Texas

vii

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viii List of Contributors

Russell Lam, MD Leila Mureebe, MD, FACS

Division of Vascular Surgery Division of Vascular Surgery
Department of Surgery Columbia University Medical Center
Cornell University Weil Medical College New York Presbyterian Hospital
New York, New York New York, New York

W. Anthony Lee, MD Joseph J. Naoum, MD

Division of Vascular Surgery
Division of Vascular Surgery & Endovascular
Therapy Department of General Surgery
The University of Texas Medical Branch
University of Florida
Galveston, Texas
Gainesville, Florida

Liz Nguyen, MD
Peter H. Lin, MD
Division of Vascular Surgery and Endovascular
Division of Vascular Surgery and Endovascular
Therapy
Therapy
Michael E. DeBakey Department of Surgery
Michael E. DeBakey Department of Surgery
Baylor College of Medicine
Baylor College of Medicine
Houston, Texas
Houston, Texas

Mai Pham, MD
Alan B. Lumsden, MD Department of Cardiothoracic and Vascular
Division of Vascular Surgery and Endovascular Surgery
Therapy University of Texas Health Science Center at
Michael E. DeBakey Department of Surgery Houston
Baylor College of Medicine Houston, Texas
Houston, Texas

Eric Peden, MD
Daniel J. Martin, MD Division of Vascular Surgery and Endovascular
Division of Vascular Surgery Therapy
Department of Surgery Michael E. DeBakey Department of Surgery
University of Florida Baylor College of Medicine
Houston, Texas
Gainesville, Florida

Ross Milner, MD
Gordon M. Riha, BS
Division of Vascular Surgery and Endovascular
Division of Vascular Surgery
Therapy
Department of Surgery
Michael E. DeBakey Department of Surgery
Emory University School of Medicine
Baylor College of Medicine
Atlanta, Georgia Houston, Texas

Imran Mohiuddin, MD Rakesh Safaya, MD

Division of Vascular Surgery and Endovascular Division of Vascular Surgery and Endovascular
Therapy Therapy
Michael E. DeBakey Department of Surgery Michael E. DeBakey Department of Surgery
Baylor College of Medicine Baylor College of Medicine
Houston, Texas Houston, Texas

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 List of Contributors ix

Eric J. Silberfein, MD Wei Zhou, MD

Division of Vascular Surgery and Endovascular Division of Vascular Surgery and Endovascular
Therapy Therapy
Michael E. DeBakey Department of Surgery Michael E. DeBakey Department of Surgery
Baylor College of Medicine Baylor College of Medicine
Houston, Texas Houston, Texas

Michael B. Silva, Jr., MD

Department of Vascular Surgery
Cleveland Clinic Foundation
Cleveland, Ohio

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LLBC: “fm” — 2005/10/29 — 16:54 — page x — #10
Foreword

Alittle more than a half-century has elapsed since the first “homemade” Dacron
graft was first used successfully to restore continuity following resection of
an aneurysm of the abdominal aorta. This, along with a number of other
essential advancements in our basic understanding of the anatomic-pathologic
aspects of aneurismal and occlusive diseases of the aorta and major arteries
and innovative technologic surgical procedures to restore circulation, led to
the establishment of highly successful therapy for most vascular diseases that
previously meant only suffering and death. Concomitant with these advances
was the development of newer and more precise diagnostic procedures, includ-
ing particularly ultrasound, computerized axial tomography (CAT) scans, and
magnetic resonance imaging (MRI), all of which have led to the advent of a
new specialty in medicine – vascular surgery.
In many respects, these sophisticated scientific and technologic advances
set the stage within the past two decades for the highly innovative develop-
ment of endovascular therapy. Once this concept was recognized, an increasing
number of investigators from a variety of disciplines, ranging from surgery, car-
diology, and radiology to bioengineering and industrial technicians, focused
their interest and energies on implementing this concept with rapidly improv-
ing clinical results. As a consequence, endovascular therapy has now replaced
a number of open surgical procedures and expanded the therapy of some
patients, who would otherwise be eliminated because of the unacceptable risk
of operation, as, for example, an elderly patient with a ruptured aneurysm of
the abdominal aorta and poor cardiac, pulmonary, or renal function.
This textbook on endovascular therapy is not only timely, but also valuable
in providing current knowledge of this expanding field. The authors, all of
whom are not only highly experienced but also contributors to this advancing
form of vascular therapy, have provided a succinct but comprehensive text that
will be useful not only to those working in this specialty, but to all physicians
and surgeons concerned with vascular disease.

Michael E. DeBakey, md
Chancellor Emeritus
Olga Keith Wiess and Distinguished Service Professor
Michael E. DeBakey Department of Surgery
Director, DeBakey Heart Center
Baylor College of Medicine
Houston, Texas

xi

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LLBC: “fm” — 2005/10/29 — 16:54 — page xii — #12
Preface

The treatment of vascular disease has evolved significantly over the past
two decades with a greater emphasis on catheter-based interventions. This
evolution has been energized by various factors, including the widespread
acceptance of minimally invasive therapy, miniaturization of endovascular
devices, and enhanced healthcare cost-effectiveness due in part to increased
outpatient treatment. Vascular physicians and patients alike have largely
embraced this minimally invasive therapy with enthusiasm due to reduced
procedural-related discomfort and faster convalescence, when compared to
the traditional operations. The continual evolution of catheter-based techno-
logies has created a need for updating and educating physicians from varying
specialty disciplines with regards to the new treatment paradigm. Equally
important, this has placed an increased demand on students and residents to
learn not only the fundamental knowledge of vascular disease but also modern
therapeutic modality.
Because endovascular therapy has become an integral component of the
overall care in vascular disease management, an understanding of the fun-
damental knowledge regarding the vascular pathology and modern catheter-
based interventions for vascular diseases will undoubtedly enhance the ability
of physicians to provide quality care to their vascular patients. Toward that
effort, we have embarked on the development of this book to achieve two
objectives. The first is to provide a general overview of the vascular dis-
eases based on their respective circulatory anatomy. This is particularly geared
toward medical students, residents, or healthcare providers with limited
background knowledge in vascular intervention. The second is to provide
a practical reference of catheter-based therapeutic modalities for vascular
physicians specializing in peripheral intervention.
Since endovascular interventions can be performed by physicians from
different specialty disciplines, this book is written to provide a general
understanding of the clinical manifestations, treatment indications, and dia-
gnostic evaluations for healthcare providers dedicated in the treatment of
vascular disease. In addition, a basic knowledge of the pathophysiology
of vascular disease, interventional techniques, and endovascular modalit-
ies of various disease categories is provided. Emphasis is also placed on
the relevant complications associated with the wide spectrum of endovas-
cular interventions. It is our hope that this book of Endovascular Therapy:
Principles of Peripheral Interventions will provide both a comprehensive and

xiii

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xiv Preface

practical reference for healthcare practitioners, regardless of their training

background or specialty disciplines, in their clinical practice of endovascular
therapy.

Alan B. Lumsden, md
Peter H. Lin, md
Ruth L. Bush, md
Changyi Chen, md, phd

LLBC: “fm” — 2005/10/29 — 16:54 — page xiv — #14

Acknowledgments

The creation of this book would not have been possible without the efforts and
support from many people. To Dr. Michael E. DeBakey, we appreciate your
support in our commitment to create this first endovascular textbook from
the Baylor College of Medicine. To the contributors, we are indebted to the
precious time and quality work you have provided to all the chapters. And
lastly to our families, Terry, Donal, Sarah, Cynthia, Pete, Cathy, Aaron, Amber,
and Bill, thank you for your tolerance and support to make this project a reality.

ABL, PHL,
RLB, CC

xv

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LLBC: “fm” — 2005/10/29 — 16:54 — page xvi — #16
CHAPTER 1

General principles of endovascular

therapy
Imran Mohiuddin, Panagiotis Kougias, Ross Milner

Cardiovascular disease remains a major cause of mortality in the developed

world since the beginning of the twenty-first century. Although surgical revas-
cularization has played a predominant role in the management of patients with
vascular disease, the modern treatment paradigms have evolved significantly
with increased emphasis of catheter-based percutaneous interventions over
the past two decades. The increasing role of this minimally invasive vascular
intervention is fueled by various factors, including rapid advances in imaging
technology, reduced morbidity, and mortality in endovascular interventions,
as well as faster convalescence following percutaneous therapy when com-
pared to traditional operations. There is little doubt that with continued device
development and refined image-guided technology, endovascular interven-
tion will provide improved clinical outcomes and play an even greater role in
the treatment of vascular disease. In this chapter, a framework is provided for
a brief history of endovascular therapy along with an overview of commonly
used endovascular devices. The fundamental techniques of percutaneous
access is also discussed.

Brief history of endovascular therapy

Evolution of diagnostic imaging
The discovery of the X-ray imaging system by Charles Röentgen in 1895,
marked one of the most remarkable milestones in the history of medicine.
Within months after its discovery, X-rays were used by battlefield surgeons to
locate and remove bullet fragments.1 This imaging modality quickly gained
acceptance from physicians around the world in providing valuable diagnostic
information in the care of their patients. As a natural evolution of this discovery,
X-rays were soon adapted to evaluate the vascular system in conjunction with
the use of a contrast material. In 1910, Frank performed the first venography
in rabbits and dogs by injecting a solution of bismuth and oil intravenously
and following its flow fluoroscopically.2 Heuser is credited (in 1919) for per-
forming the first contrast study in humans by injecting a solution of potassium
iodide into the dorsal vein of a child and following the flow of the substance
to the heart.3 The use of such materials was initially quite toxic. This led to the

LLBC: “chap1” — 2005/10/29 — 16:52 — page 1 — #1

2 Chapter 1

development of safe contrast media, for example water soluble iodine-based

organic contrast called Selectran-Neutral by Binz in 1929.4 Concurrently, newer
injection methods were also being developed. In 1927, Moniz was the first to
perform direct arterial injections, and he used this technique to inject sodium
iodide into the internal carotid arteries.5 This direct approach was initially
used to image the heart and thoracic aorta but was soon abandoned due to its
hazards.
Castellanos used an indirect method of injection whereby a contrast agent
was injected into a vein in the arm and, after a delay, the aorta was visualized.6
Due to dilution of the agent in the heart and lungs, the aorta could be visualized
only 75% of the time. For a better study of these vessels, Werner Forssmann,
a resident surgeon in Berlin in 1929, ran a urethral catheter through his own
basilic vein to visualize his right ventricle. This earned him the Nobel prize
in 1956.7 Also in 1929, dos Santos et al. described a technique of visualiz-
ing the aorta using a direct puncture technique by translumbar injection of a
contrast medium directly into the abdominal aorta.8 The modern aortogram
via a femoral approach was first performed by Farinas in 1941,9 a technique
that was quickly adapted by physicians around the world. With the advent
of guidewires in the early 1950s, selective angiography with catheter-directed
injection was developed further. In 1962, Guzman and colleagues reported a
large series of patients who underwent coronary angiography using selective
coronary catheterizations.10 Since then, the application of guidewires, cathet-
ers, and introducer sheaths has become a standard approach when performing
diagnostic angiography.

Evolution of therapeutic interventions

Ivar Seldinger, a Swedish radiologist, was the first physician to describe
a unique method of establishing arterial access using a guidewire tech-
nique in 1953, which heralded an evolution from diagnostic to therapeutic
angiography.11 A decade later, Fogarty detailed the use of a balloon-tipped
catheter to extract thrombus.12 Building on this, Dotter and Judkin in 1964
described a method of dilating an arterial occlusion using a rigid Teflon cath-
eter to improve the arterial circulation.13 In the field of venous intervention,
catheter-based vena caval filters were introduced by Greenfield in 1973, and
have revolutionized the current approach in the prevention of pulmonary
embolism.14 The technique of balloon angioplasty was introduced by Gruntzig,
who performed the first coronary artery intervention in 1974.15 To this day,
this remains the most commonly performed endovascular procedure in clin-
ical practice. The application of the balloon angioplasty catheter subsequently
led to the development of the first intravascular balloon-expandable stent by
Palmaz et al. in 1985.16 Several years later, Parodi, an Argentinean vascular sur-
geon, combined both a Dacron graft and balloon-expandable stent technology
to create a stent-graft, which was successfully used to exclude an abdominal
aortic aneurysm from the systemic circulation.17 Technology in this field is
rapidly evolving and more complex modular stents with thermal memory are

LLBC: “chap1” — 2005/10/29 — 16:52 — page 2 — #2

 General Principles of Endovascular Therapy 3

in use today. There has also been an explosion in catheter-based technology,

enabling access for the interventionalist to treat occlusive disease and increas-
ingly, aneurysmal disease in nearly every vascular bed. Further development
of this minimally invasive intervention is currently focused on combining a
pharmacological agent with the current stent platform to create drug-eluting
stents to improve the clinical outcome of endovascular therapy.

Basic vascular access

Percutaneous access can be achieved by a single- or double-wall puncture
technique. In the former approach, a beveled needle is introduced, and a
guidewire is passed after confirmation of arterial or venous access by visual
inspection of back bleeding with or without the use of direct pressure meas-
urement and inspection of arterial or venous waveforms. As a routine, we
typically gain vascular access using a 21-gauge micropuncture needle and
a 0.018-in. wire. The double-wall technique requires the use of a blunt needle
with an inner cannula. The needle is inserted through the vessel, and then the
inner cannula is removed, the introducer needle withdrawn until back bleed-
ing is obtained, and a wire introduced. Although percutaneous access can be
routinely achieved in nearly all patients, those with scarred access sites from
prior interventions or patients with decreased pulses due to occlusive dis-
ease represent a specially challenging subset that may benefit from ultrasound
guidance with Doppler insonation or B-mode visualization of the target vessel.
Indeed, access site needles have been developed with integrated Doppler
probes.

Retrograde femoral access

Percutaneous retrograde femoral puncture is the most commonly used arter-
ial access technique. Both groins are prepped and draped in a sterile fashion.
Visualization of the femoral head using fluoroscopy is recommended. In the
majority of patients, the common femoral artery can be found over the medial
third of the head of the femur (Figure 1.1). Another advantage of access-
ing the artery in this location is that the femoral head will serve as a hard
surface to compress the artery against, after the completion of the proced-
ure if manual compression is needed to achieve hemostasis. An 18-gauge
angiographic needle is then advanced at a 45◦ angle through the skin until
pulsatile back bleeding is encountered. As with all needle access, the bevel of
the needle should point upward. Going through and through the artery should
be avoided, as this can lead to problematic bleeding. Depending upon the body
habitus, the artery may lie anywhere from 2–5 cm below the level of the skin. If
venous entry is noted, it is useful to remember that the artery lies lateral to the
vein. It is also important to remember that there is approximately 3 cm of com-
mon femoral artery that lies between the inferior ligament and the femoral
bifurcation. Once brisk back bleeding is noted, a standard Bentson wire is
passed through the needle into the artery for at least 20 cm. It is recommended

LLBC: “chap1” — 2005/10/29 — 16:52 — page 3 — #3

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