How to Determine Optimal Balloon Size in Below-the-Knee Angioplasty

Unlike the coronary and femoral arteries, calcification of medial layers in infrapatellar arteries prevents positive remodeling and expansion capacity to maintain vessel lumen. 

La endarterectomía precoz parece superior a la angioplastia carotidea en pacientes sintomáticos

Long term patency of endovascular treatment is suboptimal despite the coated balloons, atherectomy devices and stents. 

Standard angiographies only show vessel lumen far from its real dimension given the severe thickening of the medial layer. 

Balloon dimension will vary considerably, seeing as it depends on operators’ criteria, resulting in low technical success when they turn out to be far smaller than the artery, or in dissections and ruptures, when they are over dimensioned. Dissections significantly reduce patency, whether they are treated with stents or not. 

This small study on cadaver arteries might shed some light or generate hypotheses on under and over expanded vessel behavior. 


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Arteries were randomized to angioplasty with 3.0 vs 4.0 mm balloons inflated at normal pressure.

After dilation, there was 1.9 ± 0.3 mm to 2.3 ± 0.2 mm lumen gain, with no significant gain with the 4 mm balloon (0.3 ± 0.2 mm vs. 0.5 ± 0.4 mm; p=0.21).

Overdilation with balloon angioplasty with respect to vessel diameter moderately correlated with increased lumen.


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Dissection severity consistently correlated with increased calcification, even though there were variations according to calcification distribution. 

In arteries with nodule calcification severe dissection was often found with overdilation, which is why it should be prevented, or we should look into select implantation when it comes to stents in this type of lesions. 

Instead, arteries with circumference calcification (also considered severe) showed limited damage when overexpanded and a clear benefit in terms of luminal gain.


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Knowing the correct size and distribution of calcium with intravascular ultrasound to be able to choose the correct balloon/artery diameter ratio might be the key to minimizing damage and maximizing luminal gain. 

Título original: Vessel Calcification Patterns Should Determine Optimal Balloon Size Strategy in Below the Knee Angioplasty Procedures.

Reference: Rutger H.A. Welling et al. Eur J Vasc Endovasc Surg 2020 Jul 2;S1078-5884(20)30454-8. doi: 10.1016/j.ejvs.2020.05.032.


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