Angioscopy in endovascular surgery: recent technical advances to enhance intervention selection and failure analysis

Recent technical and procedural modifications have greatly enhanced the usefulness of angioscopy during angioplasty. A pulsed irrigation system, proximal and distal blood flow control by pressure, and attention to sheath/vessel diameter ratio were incorporated into a study in which angioscopy was used for pretreatment assessment in 23 patients with symptomatic peripheral vascular disease presenting for initial (8 patients) evaluation or repeat treatment (15 patients) following a previous vascular procedure. Twenty-five lesions were examined with a 2.3 mm flexible angioscope equipped with an irrigating lumen; there were no complications attributable to angioscopy. The angioscope was useful in the characterization of lesions for selection of the recanalization technique. Lesions more amenable to initial atherectomy were visualized in 12 patients; 7 occlusions were successfully treated with laser/balloon angioplasty, with angioscopy assisting in probe and/or wire passage in 4 cases. Three late reocclusions were identified angioscopically as due solely to thrombosis, indicating the need for thrombolytic therapy. Angioscopy also identified 4 cases of incomplete recanalization despite a satisfactory arteriographic image. Angioscopy was also used to evaluate stenotic lesions unaccompanied by thrombus formation in patients previously treated with laser-assisted angioplasty. Histologic evaluation of the biopsied plaques identified intimal hyperplasia as the etiology, matching identically similar specimens harvested from a lesion treated with balloon dilation only.