Peripheral Vascular Disease and Interventions vii

CONTENTS
Foreword: Peripheral Vascular Interventions xiii
Marvin H. Eng

Preface: Peripheral Arterial and Venous Disease: A “Head-to-Toe” Vascular xv

Journey
Dmitriy N. Feldman and Andrew J.P. Klein

Optimal Medical Therapy in Peripheral Artery Disease 137

Ju Young Bae and Elissa Altin
Peripheral artery disease (PAD) is a highly prevalent subset of cardiovascular
disease associated with significant limb-related and concomitant atheroscler-
otic complications, resulting in high morbidity and mortality. Consequently,
appropriate identification and timely initiation of guideline-directed medical
therapy is crucial. Despite its widespread prevalence, PAD remains underdiag-
nosed and undertreated, posing a substantial public health challenge. This
review delves into the evidence-based nonpharmacological and pharmaco-
logic treatment strategies for PAD, underscoring the necessity of a multidisci-
plinary approach.

Vascular Access and Management of Complications 149

Aman Kansal, William Schuyler Jones, Sanjum S. Sethi, and Jennifer A. Rymer
Vascular access requires a deliberate and thoughtful approach. Optimal femo-
ral access involves understanding anatomic, fluoroscopic, and ultrasound prin-
ciples. Combining all 3 approaches optimizes femoral access and minimizes
complications, with ultrasound guidance showing the most promising results
for procedural success and safety. Transradial access for PCI and peripheral
interventions offers benefits like reduced complications, shorter hospital stays,
and improved safety. However, challenges include equipment limitations,
radial spasm, and procedural complexity. Lower extremity interventions carry
risks of access site complications. Prevention involves careful access technique,
imaging, and timely management, including endovascular or surgical interven-
tions for severe cases.

Intravascular Imaging in Peripheral Endovascular Intervention: A Contemporary 161

Review
Daniel J. Snyder, Robert S. Zilinyi, Takehiko Kido, and Sahil A. Parikh
Peripheral arterial disease affects more than 10 million individuals in the United
States and over 200 million people worldwide. In the past, the majority of
patients were treated with open bypass surgery, but an increasing number
are now treated with minimally invasive peripheral endovascular intervention
(PVI). To be successful, operators are reliant on the quality of the imaging
data obtained during the case. This article reviews the data supporting the
use of intravascular imaging in PVI, focusing specifically on lower extremity
arterial interventions.

Endovascular Abdominal Aortic Aneurysm Repair 173

Zafar Ali, Luke Kim, and Kamal Gupta
A great majority of abdominal aortic aneurysm are treated with endovascular
aortic repair (EVAR) in current practice. EVAR has lower peri-procedural
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mortality and morbidity compared to open surgical repair. Anatomic factors

such as aneurysm neck morphology, iliac anatomy, and access vessel anatomy
need careful assessment for the successful performance of EVAR. Evolving
technology and techniques are allowing more patients to be treated with
EVAR with better long-term outcomes.

Carotid Disease and Management 191

Khawaja Hassan Akhtar, David C. Metzger, and Faisal Latif
Carotid artery stenosis is a leading cause of stroke, and 25% of patients experi-
ence a recurrent stroke within 5 years. Early detection and treatment are impor-
tant to reduce the risk of stroke. Optimal medical therapy should be ensured
among these patients regardless of symptom status. Carotid artery revasculariza-
tion with carotid endarterectomy or carotid artery stenting (CAS) should be con-
sidered among patients with symptomatic carotid stenosis, or among patients
with severe asymptomatic carotid artery stenosis. Refined procedural techniques,
improvement in stent design, and use of embolic protection devices have
enhanced the efficacy of CAS while reducing the risk of procedural complications.

Renal and Mesenteric Artery Intervention 205

Jose D. Tafur, Khanjan B. Shah, and Christopher J. White
Atherosclerotic disease of the abdominal aorta and its visceral branches poses
significant health risks due to its potential to cause severe complications. Athe-
rosclerosis affects renal and mesenteric vessels, contributing to renal artery
stenosis and mesenteric ischemia, respectively, both of which can result in organ
damage and ischemic bowel disease if left untreated. Therapy with guideline-
directed medical therapy is advised in all patients. Chronic mesenteric ischemia
(CMI) is infrequent and difficult to diagnose illness. Current evidence suggests
that compared with open surgical repair, in anatomically suitable lesions, endo-
vascular therapy is the most cost-effective choice for patients with CMI.

Renal Denervation: A Review of Current Devices, Techniques, and Evidence 225

Monica Tung, Taisei Kobayashi, Rajesh V. Swaminathan, Debbie L. Cohen,
Dmitriy N. Feldman, and Brian Fulton
Hypertension is a major contributor to morbidity and mortality in the United
States, and its management remains a significant challenge for clinicians.
Transcatheter renal denervation targeting sympathetic nervous system overac-
tivity offers an additive benefit to medications for patients with uncontrolled
hypertension as well as for patients who are not able or unwilling to be treated
with medications. Two devices were recently approved for commercial use that
employ radiofrequency ablative and ultrasound energy for renal denervation.
Both devices have shown durable treatment effects up to 3 years with minimal
device-related safety concerns.

Iliac Arterial Intervention 235

Jacob Ricci, Hillary Johnston-Cox, and Andrew J.P. Klein
Peripheral arterial disease affects a large patient population, and a large per-
centage of these patients have evidence of aortoiliac occlusive disease. This
review discusses the evaluation and characterization of iliac lesions as well as
the associated interventional procedures focusing on techniques, device
choice, potential complications, and postprocedural care. We discuss stent
choice and studies aimed at analyzing the outcomes associated with each
type as well as a brief discussion of intravascular lithotripsy which is quickly
becoming a popular plaque modifier in endovascular procedures.
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Femoropopliteal Interventions for Peripheral Artery Disease: A Review of 243

Current Evidence and Future Directions
Adam P. Johnson, Rajesh V. Swaminathan, Samantha D. Minc, and
Jorge Antonio Gutierrez
The femoropopliteal segment is a common anatomic location for peripheral
artery disease. The clinical presentation of occlusive disease of the femoropo-
pliteal segment can range from symptomatic or severe claudication if in isola-
tion, or acute or chornic limb threatening ischemia often in the setting of
multilevel disease. Patients can be treated with various therapies to improve
symptoms and restore perfusion, including medical, exercise, endovascular,
and open surgical therapies. The current literature is rapidly evolving on the
best management algorithms and strategies based on patient presentation,
severity of occlusive disease, and desired therapy goals. This paper summarizes
current literature on available medical, endovascular, and surgical therapies for
treating peripheral artery occlusive disease of the femoropopliteal segment.

Chronic Limb-Threatening Ischemia: A Comprehensive Review Paper 257

Ghassan Daher, Satawart Upadhyay, and Jun Li
Chronic limb-threatening ischemia (CLTI) is the end-stage presentation of
peripheral artery disease and requires comprehensive care. Despite advance-
ments in treatments, providing timely and equitable care remains challenging.
Ongoing research and interdisciplinary collaboration are vital for improving
outcomes. Implementing strategies that combine appropriate diagnostics,
advanced and innovative revascularization techniques, guideline-directed med-
ical therapies, and efforts to tackle socioeconomic disparities can better
address patient needs and enhance quality and quantity of life. This multifac-
eted approach offers promise for improved long-term outcomes in CLTI
patients.

Acute Limb Ischemia Interventions 273

Asmaa Ahmed, Nauman Naeem, Aakriti Jain, Sahej Arora, and Islam Y. Elgendy
Acute limb ischemia (ALI) is characterized by a sudden decrease in limb perfusion
that threatens the viability of the limb. ALI can result from various causes including
arterial embolism, thrombosis, or trauma. The diagnosis is predominantly clinical,
guided by the “6 Ps” mnemonic—pain, pallor, pulse deficit, paralysis, paresthesia,
and poikilothermia—and confirmed through imaging modalities if needed. Treat-
ment decisions are informed by the Rutherford classification, ranging from viable
to irreversibly damaged limbs. Early diagnosis and timely intervention are critical
for improving limb salvage and reducing amputation rates.

Chronic Venous Insufficiency and Management 283

Robert R. Attaran, Golsa Babapour, Carlos Mena-Hurtado, and
Cassius Iyad Ochoa Chaar
Chronic venous insufficiency is common and is associated with progressive leg
discomfort, heaviness, edema, discoloration and ulceration, and venous
obstruction, reflux, or both. Venous insufficiency and varicose veins are wide-
spread and are common in Western countries. Risk factors include age, female
gender, positive family history, pregnancy and parity, obesity, prolonged
standing, and history of deep vein thrombosis. Chronic venous disease is the
leading etiology of leg ulcers, which are associated with poor quality of life.
Compression, pharmacologic therapy, and catheter-based techniques have
shown promise for deep vein recanalization, closure of incompetent superficial
veins, and elimination of varicose veins.
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Iliofemoral Acute Deep Venous Thrombosis, Chronic Deep Venous Thrombosis, 297
and May-Thurner Syndrome
Anthony Teta, Jay Mohan, Vincent Varghese, Jon C. George, Jacqueline Powers,
Ehrin J. Armstrong, and Yulanka Castro-Dominguez
Acute iliofemoral deep vein thrombosis (DVT) is associated with higher rates of
severe chronic symptoms and complications, and in rare cases with acute limb
ischemia. Early detection is a key to provide prompt treatment, including endo-
vascular intervention, in selected patients. When iliofemoral DVT is related to
external compression of the left iliac vein by the right common iliac artery is
termed May-Thurner syndrome. Approximately, 20% to 50% of patients with
chronic DVT will develop post-thrombotic syndrome, a collection of symptoms
including lower extremity edema, skin changes, vein dilation, pain, fatigue, and
ulcer formation.