[Percutaneous angioscopy and angioplasty in the treatment of arteriopathies of the lower limbs]. / Angioscopie et angioplastie percutanées dans le traitement des artériopathies des membres inférieurs.

Since 1987, the authors have routinely combined angioscopy with angioplasty of peripheral arteries. In a series of 251 angioplasties carried out in 191 patients, angioscopy was found to be more specific and more sensitive than arterial angiography in the etiological diagnosis of arterial stenoses and/or obstructions. Angioscopic findings modified the angioplasty procedure in 29% of cases. Using an inflatable catheter remains the most commonly used approach (230 cases); in 10 cases, this was preceded by thromboaspiration and in 4 cases by dotterization. Angioscopic support was useful in carrying out difficult manoeuvres (monitoring of the angioplasty in 4 cases, correct orientation of the guide into the lumen in 14 cases, installation of an endoprosthesis in 9 cases, arterial biopsy in 5 cases and sampling of an atheroma in 8 cases).

[Angioscopy of lower limb arteries. History and technique, cost and practical information]. / Angioscopie des artères des membres inférieurs. Historique et technique, coût et informations pratiques.

The historical background to angioscopy shows that the principal successes recorded by its use result from the miniaturization of fibroscopes and the progress in video imaging. The first tentative use of angioscopy was by surgeons during operations carried out at about 1970, that of percutaneous angioscopy dating from 1984. The material used for diagnostic (fibroscope, cinecamera, video system, flushing pump) and interventional (fibroscope, clamps, Dormia cage, endoprostheses ... ) angioscopy is such that the basic equipment requires an outlay of about 150 to 200,000 francs. Percutaneous angioscopy implies the insertion of a catheter allowing flushing of the arterial lumen by means of a pressurized perfusion pump which, when reversed, is transformed into an aspirating pump for removal of the clot and/or atheromatous debris. The procedure is simple and does not expose to more complications than conventional arteriography.

[Percutaneous diagnostic angioscopy. Primary lesions]. / Angioscopie percutanée diagnostique. Les lésions élémentaires.

Efficacy of percutaneous treatments of arterial affections requires the correct choice of indications, necessitating precise knowledge of elementary arterial lesions. Arterial endoscopy appears to be more specific than angiography for this use, since it allows direct vision in vivo of the lesion, a histopathologic approach compared with the non univocal images produced by angiography (for example, an arterial obstruction can result from varied causes). Different accidents to the endothelial surface can be observed: golden yellow atheromatous elevations on a straw yellow background, intimal flaps, mobile intra-luminal vegetations. Established atheromatous stenosis are smooth and regular, or on the contrary ulcerated and edged with irregular flaps capable of provoking an eccentric residual lumen. The vegetating atheromatous lesions may project into the lumen, often as calcified and thus pearly white scales adhering to the wall, or as larger occlusive lesions. When capable of being isolated, a thrombus often completes the stenosis: its recognition is therefore fundamental since its removal exposes the subjacent lesions to be treated. The fresh clot is coral shaped, bright red and mobile in the blood flow. Established clots are compact and greenish brown. At an advanced stage of atheroma the surface of the occluding clot is covered with a regular straw yellow endothelium. In the presence of a dissecting vessel the fibroscope may be introduced into the false channel, no longer showing typical endothelium but a coagulated mass interspersed with fibrous bands. Prosthetic stenosis result from either intimal hyperplasia or a suturing fault with plication.

[Interventional angioscopy]. / Angioscopie interventionnelle.

Since 1987, routine angioscopic examination has been performed in 191 patients undergoing angioplasty, with interventions (196) after a 2 year surveillance period (55). Angioscopy allowed follow up "de visu" of the performance of angioplasty, details of its mechanism to be precise and under dilatation to be carried out. For femoral artery occlusions it allowed treatment "à la carte": conventional dilatation of vegetating atheroma, specific treatment of established thrombi (5) and abstention from therapy of atheroma covered by endothelium (3). It also enabled fresh thrombi complicating a stenosis or at the origin of a thrombus to be detected. The extraction technique employed (15) is described. It facilitated catheterization by directing the probe, enabled avoidance of bypassing of stenosis and flaps and of dissection or false introduction into collaterals (10). Directed biopsy could be carried out in inflammatory arteritis (7). Vegetating atheromatous lesions could be opened and extracted, facilitating subsequent dilatation and allowing an approach to removal of iliac artery obstructions without major risks of complications (13). Finally, after an ineffective dilatation or the presence of a dissection, it assisted making the decision to introduce a stent (9), the tolerance and outcome of these stents are described. Or the 196 patients considered suitable for angioplasty, our therapeutic conduct was modified by angioscopy in 58 cases (29%). Not simply a new diagnostic tool, it plays a role in interventional vascular techniques.

[Angioscopy of the pulmonary arteries]. / L'angioscopie des artères pulmonaires.

The endoscopic investigation of the pulmonary arteries was developed during the 1980's. Current angioscopic techniques, which are still very limited in availability, enable an accurate endoluminal view and allow for a direct approach to endovascular obstruction. The authors describe the technique of angioscopy of the pulmonary arteries and also its indications.

[Percutaneous angioscopy in the diagnosis of arteriopathies of the lower limbs]. / L'angioscopie percutanée dans le diagnostic des artériopathies des membres inférieurs.

Because of the poor specificity of the arteriography, the authors have performed a percutaneous angioscopy before every angioplasty of the arteries of lower limbs for nearly 3 years. They define the angioscopy and describe materials and technique. The percutaneous route without surgery and without anesthesia underlines the originality of the technique. The great difficulty is to counter-pulse the arterial inflow. The rate of saline irrigation and all the means of arterial blockade are described. In the second part, the "elementary images" are classified. The authors insist on the specificity of the angioscopy in the interpretation of arterial obstructions. Because of this specificity, the right treatment can be applied to any type of lesion. Angioscopy permits to foresee endoluminal surgery technique.

[Femoral angioplasty. Long-term results]. / Les angioplasties fémorales. Résultats à long terme.

A study on the long-term efficacy of femoral-popliteal angioplasty was carried out on 185 angioplasty cases over a 5 year follow-up period. A classification of data according to the type of lesion treated, revealed that results were favorable in case of stenosis (87%), short obstruction (70%) and long obstruction (35%). A special study of the outcome of treatments for stage IV arteritis was carried out. After comparing results with those obtained by other teams, the authors list the complications encountered, hematomas, and thromboses, and show their current tendency for regression. Lastly, the authors stress the advantages of angioscopy, which permits to identify the nature of the treated lesions and to predict possible complications, which are usually underrated by angiography.

[Long-term results of percutaneous transluminal angioplasty of the iliac arteries]. / Résultats à long terme des angioplasties percutanées transluminales des artères iliaques.

A well-mastered technique will cause percutaneous transluminal angioplasty of iliac arteries to achieve long-term results comparable to those obtained surgically. In isolated iliac stenosis, a 95% good result rate is attained (81% cured, 14% improved). More complex cases of iliac stenosis yield 90% good results (72% cure), with a mean Doppler ankle/arm pressure index gain of 0.5 point in a series including 673 patients at 5 years follow-up. Only the presence of combined distal femoral lesions may cause the good result score to drop to 85%, including merely 35% cure. General complications are practically lacking and local complications are minimal, which incites one to propose this technique as a first-line treatment of iliac stenosis whenever distal blood circulation is maintained.

[Angioscopy and angioplasty of the iliac and femoral arteries]. / Angioscopie et angioplastie des artères iliaques et fémorales.

Angioscopy is a technique of endoscopic investigation of the vascular lumen and its contents, which we have coupled with iliac and femoral angioplasty. The material comprises 3 main elements: the angioscope, the TV-monitoring assembly and the infusion system. No complication was recorded in a series of 94 angioscopies (47 iliac, 44 distal femoral and 3 grafts) performed over a period of 18 months. The technical quality of the images obtained was good in 90% of cases (85/94). Angioscopy revealed lesions that had either been nonvisualized or underrated by angiography, and played a determinant role in 16% of cases (15/94), whereby the therapeutical procedure could be modified accordingly.

[Long-term results of transluminal angioplasty in the treatment of stenosis of the renal artery]. / Résultats à long terme de l'angioplastie transluminale dans le traitement des sténoses de l'artère rénale.

MATERIALS AND METHODS. A multicenter study was undertaken to determine the long-term results of renal angioplasty. Five teams with considerable experience in the procedure replied to a computerized questionnaire concerning transluminal angioplasty (TLA) performed with immediate success from 1979 to 1985 and followed up regularly (minimum of four years). The main purpose of the study was to assess the long-term results, both anatomical results and clinical, of renal TLA. Consideration was given to anatomical of average quality and their possible correlation with long-term results, in an attempt to foresee and even prevent restenosis. The main points of the study are given in figure 1. Two hundred and forty-seven renal TLA performed in 210 patients were included (insofar as clinical and radiologic follow-up was adequate, with a minimum of one control angiography beyond six months). Patients who had immediate failure (dilatation not possible or ineffective dilatation) were excluded from the analysis of long-term results. Likewise, TLA of the renal artery of grafted kidneys were not included in this study. The histogram of patients ages shows a clear predominance of subjects 60 to 65 years of age, with extremes ranging from 10 to 80 years (mean 53 years). TLA were done mainly by the femoral route according to a technique using a balloon catheter positioned on a previously inserted guide at the level of the stenosis. The examination was performed under local anesthesia. Balloon size was determined according to the diameter of the renal artery upstream from the stenosis and that of the contralateral renal artery. A balloon of the same or slightly larger caliber was used. The indication of angioplasty was determined after multidisciplinary discussion according to two main criteria: First, treatment of hypertension presumed to be in relation with a stenosis of the renal artery (renovascular hypertension). Secondly, conservation of the nephrotic capacities of a patient with a renal stenosis possibly associated with arterial hypertension, in relation with a bilateral stenosis of the renal arteries or with a unilateral stenosis affecting a functionally or anatomically single kidney. In this latter case, the purpose of TLA was to avoid development toward thrombosis of the renal artery and worsening of renal insufficiency. RESULTS. Two hundred and forty-seven TLA in 210 patients were included in the study. Nineteen patients (9%) had bilateral TLA. The lesions treated are indicated in figure 3. These were most often simple atheromatous and truncal lesions of the renal artery (73%) which were significant (greater than 50%) in 99% of cases. TLA was indicated in 77% of cases for treatment of arterial hypertension presumed to be renovascular. In 23% of cases, treatment of the stenosis was intended to conserve, especially, kidney vascularization, i.e., an indication of nephrotic protection. There were 9.7% immediate failures...

[Percutaneous angioscopy of the iliac and femoral arteries]. / L'angioscopie percutanée des artères iliaques et fémorales.

Very few papers about peripheral angioscopy are reported in literature. Percutaneous angioscopy (P.T.A.) of 25 peripheral arteries (21 iliac and 4 femoral arteries) have been performed by the authors without surgery and without anesthesia. Three observations are selected. The first one demonstrates an eccentric stenosis altering its diameter during pulsations; an irregular ulcerated atheroma is observed. The second case shows the signs of a centric atheroma with an intimal fragment. The last one is an intimal dissection due to PTA. The prospective aspects of this new technique are discussed.

Renovascular hypertension: easier diagnosis and treatment with intravenous renal arteriography and percutaneous transluminal dilatation.

For the diagnosis of renovascular disease, the authors propose the use of intravenous arteriography with photographic subtraction as the method of choice and advise the use of pyelogram wash-out to assess the functional significance of the stenosis. Furthermore they report their experience with percutaneous transluminal dilatation in 41 patients (10 fibrotic--31 atherosclerotic renal artery stenoses) and suggest that this method is valid alternative to surgery specially in poor risk patients. A controlled trial of this method versus surgery needs however to be undertaken to define the respective roles of these treatments.

[Angioplasty of the arteries of the extremities. Early and mid-term results (up to 3 years) in 492 cases]. / L'angioplastie des artères des membres. Résultats précoces et à moyen terme (jusqu'à 3 ans) sur 492 cas.

Results of iliac, femoral and/or iliac artery percutaneous transluminal angioplasty (P.T.A.) in 492 cases are presented, and the latest technical improvements in the procedure reviewed. Short and medium-term results in iliac artery stenoses were excellent (98 and 96% respectively), obstructions in this region not being treated. The advantage of P.T.A. over surgery is the lack of exposure of patients to the risk of circulatory insufficiency. Very good results were obtained in stenosis of the distal femoral artery, the method being much less effective in cases of long thrombosis. The essential indications are all types of stenosis of limb arteries, while contraindications can be summarized as iliac artery obstructions (because of possible severe retroperitoneal hematomas) and massive atheromatous calcifications. Aortic and graft stenoses are particular indications. Complications are mainly hematomas and thromboses, but these can be reduced in incidence by increasing experience of radiologists in the use of P.T.A. and by improved selection of patients. Progress will also depend on improved control of anticoagulant and thrombolytic treatments. The question is raised as to the need to treat early claudication due to femoral artery stenosis following detection by the Doppler effect test. The essential argument in favor of P.T.A. is the simplicity and safety of the method to the compared reconstructive surgery, a method involving too high a risk.