A Novel Simple Technique Using Hyperemia to Enhance Pressure Gradient Measurement of the Lower Extremity During Peripheral Intervention

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1 A Novel Simple Technique Using Hyperemia to Enhance Pressure Gradient Measurement of the Lower Extremity During Peripheral Intervention Issam Koleilat, MD; Bruce Gray, MD From Greenville Health System, Greenville, South Carolina. ABSTRACT: Purpose: To describe a novel technique coupling the use of a pressure-wire gradient measurement with and without hyperemia (induced with an external blood pressure cuff inflated to 20 mmhg above the systolic blood pressure for 1 minute on the affected calf). Case: A 70-year-old patient presented with lifestyle-limiting lower-extremity calf claudication. He underwent angiography, which revealed left superficial femoral artery stenosis. Angioplasty of the lesion improved the angiographic appearance, but a residual pressure gradient could be elicited with provocative hyperemia testing. This prompted stenting, which resolved the differential. Conclusions: Pressure-wire gradient detection with and without provocative hyperemia testing using our novel approach may prove to be a useful adjunct in the diagnosis and treatment of lower extremity occlusive disease. VASCULAR DISEASE MANAGEMENT 2015;12(9):E166-E172 Key words: hyperemia, peripheral vascular intervention, fractional flow reserve A 70-year-old patient presented with lifestylelimiting claudication. He previously had stents placed in his external iliac arteries bilaterally as well as his right distal superficial femoral artery, but he had persistent claudication of the left calf. On presentation, he had an abnormal ankle-brachial index (ABI) of 0.68 on the left. Duplex ultrasound revealed an elevated left superficial femoral artery peak systolic velocity of 384 cm/s with otherwise normal flow velocities. Upon angiography, the left common femoral, profunda femoral, and superficial femoral (SFA) arteries were all patent proximally. By the mid-thigh, heavy calcification resulted in significant stenosis and plaque burden of the SFA with the greatest degree of stenosis at Hunter s canal (at least 90% diameter stenosis) (Figures 1 and 2). The popliteal artery, anterior tibial artery, and posterior tibial arteries were patent. A resting peak systolic pressure gradient between the proximal SFA and proximal popliteal artery was 32 mmhg and was 0.88 when given as a ratio (Figure 3). Upon provocative testing with a blood pressure cuff on the calf inflated to 20 mmhg above the systolic blood pressure for 1 minute and then deflated, the pressure gradient was 58 mmhg with a ratio of 0.64 Vascular Disease Management September

Figure 1. Left superficial femoral artery arteriogram prior to any intervention. (Figure 4). These measurements were obtained with a 0.

The lesion was balloon-dilated with a 6 mm x 100 mm balloon with subsequent resolution of the lesion pressure differential (Figure 5).

Repeat testing with hyperemia revealed a pressure difference of 19 mmhg and a ratio of 0.88 (Figure 6).

2 Figure 1. Left superficial femoral artery arteriogram prior to any intervention. (Figure 4). These measurements were obtained with a Verrata Pressure Wire (Volcano Corporation). The lesion was balloon-dilated with a 6 mm x 100 mm balloon with subsequent resolution of the lesion pressure differential (Figure 5). Post-angioplasty at rest without hyperemia, the pressure gradient was 5 mmhg with a ratio of Repeat testing with hyperemia revealed a pressure difference of 19 mmhg and a ratio of 0.88 (Figure 6). Intravascular ultrasound (IVUS) confirmed the size, extent, and length of the plaque. Stenting of this Figure 2. Intravascular ultrasound of left superficial femoral artery just proximal to the lesion prior to intervention. Figure 3. Pre-intervention fractional flow reserve demonstrating a gradient across the superficial femoral artery lesion. Vascular Disease Management September

$Pre-intervention fractional flow reserve after provocative hyperemia testing$ $Post-angioplasty fractional flow reserve after provocative hyperemia testing$ $Post-angioplasty fractional flow reserve demonstrating no pressure differential.$ lesion thus required two Zilver PTX (Cook Medical) stents.

lesion thus required two Zilver PTX (Cook Medical) stents.

3 Figure 4. Pre-intervention fractional flow reserve after provocative hyperemia testing demonstrating worsening of the lesion gradient. Figure 6. Post-angioplasty fractional flow reserve after provocative hyperemia testing demonstrating a residual pressure gradient. Figure 5. Post-angioplasty fractional flow reserve demonstrating no pressure differential. lesion thus required two Zilver PTX (Cook Medical) stents. A 6 mm x 80 mm stent was placed in the distal SFA, and a 7 mm x 80 mm stent was placed just proximal to the first. The stents were post-dilated Figure 7. Post-stenting completion angiogram. Vascular Disease Management September

4 Table 1. Hemodynamic Values at Baseline (Without Hyperemia) With Provocative Hyperemia Testing Prior to Intervention, After Angioplasty, and After Stenting Pa (mmhg) Pd (mmhg) Pa-Pd (mmhg) FFR Baseline Baseline hyperemia Difference PTA baseline PTA hyperemia Difference Stent baseline Stent hyperemia Difference 1 0 PTA = percutaneous transluminal angioplasty; Pa = pressure just proximal to the lesion; Pd = pressure just distal to the lesion; Pa-Pd = absolute pressure difference across the lesion; FFR = fractional flow reserve (Pd/Pa). Figure 8. Post-stenting fractional flow reserve after provocative hyperemia testing demonstrating resolution of the pressure gradient. with a 6 mm angioplasty balloon with an excellent angiographic and hemodynamic result (Figure 7). Completion hyperemia measurements showed a pressure gradient of 1 mmhg and a ratio of 1.0 (Figure 8, Table 1). On follow-up evaluation the patient had resolution of his claudication with normal pedal pulses on examination. His ABI is normal now at 1.02 on the left. He has duplex evidence of normal flow velocities of the SFA stents as well. DISCUSSION Fractional flow reserve (FFR) measurement and its technique have previously been described for assessment of lesion severity in the coronary vasculature. 1 The pressure gradient across the lesion is obtained with the use of a pressure wire distal to the lesion (Pd) and compared to aortic pressure (Pa). While measurements of pressure gradients using pressure wires correlate with those obtained by catheter alone in the periphery, catheter-based measurements tend to overestimate the pressure gradients. 2 In the coronary bed, FFR is calculated using the difference in mean blood pressure measurements and reported using the ratio Pd:Pa. Clinical significance is defined as an FFR less than The Society for Cardiovascular Angiography and Interventions recommends using a threshold value of 0.8 for the FFR in the coronary vasculature. 4 Values under this threshold likely represent ischemiaproducing lesions and should be treated, whereas those Vascular Disease Management September

5 values obtained that are greater than 0.8 likely do not represent ischemia. Not only is FFR measurement cost effective when compared to a strategy of stenting or a strategy of adjuvant testing to further determine ischemia, 5 but FFR measurement also may predict long-term patency in the coronary bed 6,7 as well as in hemodialysis access dysfunction. 8 An FFR of less than 0.9 (i.e. a residual pressure gradient) indicates a suboptimal effect with a higher likelihood of longterm restenosis. 3,9-12 In contrast, an FFR greater than 0.9, especially if greater than 0.95, was associated with a lower rate of adverse outcome. 13 Certainly, extrapolation of this information would be consistent with previous peripheral data suggesting that normalization of the ABI to above 0.9 is predictive of improved duce the influence of collateralization. In contrast, in outcomes. 14 This technique has been used in the lower extremity leg. 18 Fortunately, the lower extremity is easily accessible for hyperemic testing by mechanically inducing transient ischemia with inflation of a blood pressure cuff placed around the calf. This creates reactive distal vasodilation and simulation of physiologic demand without the risk of sequelae due to pharmacologic infusions. This difference in technique is not only one of convenience and reduction of sequelae but also one that attempts to accommodate the difference in vascular beds under scrutiny. It is important to recognize that the physiology and the need for hyperemia differ in the periphery compared to the coronary vessels. In the coronary system, maximal vasodilation helps re- the periphery, the intent is to evaluate for residual or undiagnosed stenoses in a more dynamic or demand but with limited applicability because the therapeutic state. As a result, the technique we propose herein is threshold has not been objectively established. Despite noninvasive and angiographic assessment, estabnary vessels. different than that previously described for the corolishing the clinical and hemodynamic significance of Reactive hyperemia is not necessary diagnostically a lesion, the Pd:Pa ratio may still be calculated above for lesions that are obvious, but it may prove of greater 0.9. This creates too narrow a separation between lesions that are or are not hemodynamically significant. after angioplasty (especially drug-coated balloon). The utility in discerning the quality and normalcy of flow This window may be broadened by using the systolic interventionalist may therefore be able to better make pressure difference instead of the mean pressure values. a decision regarding provisional secondary treatment The addition of hyperemia causes transient arterial (i.e. stent, atherectomy, additional PTA) based on an vasodilation, further increasing the difference between objective endpoint compared to the subjective information obtained with traditional angiography. Addi- Pa and Pd. Reactive hyperemia in the coronary bed is typically tionally, the individual significance of each of tandem induced by intracoronary infusion of adenosine, nitroglycerine, or verapamil A single report described By combining the use of pressure wire measurements lesions may be better discerned using this technique. the use of using intra-arterial adenosine to induce of a pressure gradient with reactive hyperemic testing, hyperemia and simulate physiologic demand in the this novel approach allows for the on-table evaluation Vascular Disease Management September

6 of the success of intervention prior to conclusion of the procedure and therefore improved decision-making regarding extent of treatment. This approach does not add significant time to the procedure (approximately 1 minute for each assessment) or expense (with the exception of a pressure wire). No systemic sequelae have been identified, contrary to the significant potential side effects with pharmacologic intravascular administration such as atrioventricular block, chest pain, or dyspnea. 19 Further evaluation of this novel technique to elucidate its utility and role in routine angiography is warranted. n Editor s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no financial relationships or conflicts of interest regarding the content herein. Manuscript received November 16, 2014; provisional acceptance given February 12, 2015; final version accepted June 15, Address for correspondence: Issam Koleilat, MD, Greenville Health System, Surgery, 701 Grove Road, Greenville, SC 29605, United States. ikoleilat@gmail.com. REFERENCES 1. Vranckx P, Cutlip DE, McFadden EP, Kern MJ, Mehran R, Muller O. Coronary pressure-derived fractional flow reserve measurements: recommendations for standardization, recording, and reporting as a core laboratory technique. Proposals for integration in clinical trials. Circ Cardiovasc Interv. 2012;5(2): Garcia LA, Carrozza JP, Jr. Physiologic evaluation of translesion pressure gradients in peripheral arteries: comparison of pressure wire and catheter-derived measurements. J Intervent Cardiol. 2007;20(1): Pijls NH, Fearon WF, Tonino PA, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol. 2010;56(3): Lotfi A, Jeremias A, Fearon WF, et al; Society of Cardiovascular Angiography and Interventions. Expert consensus statement on the use of fractional flow reserve, intravascular ultrasound, and optical coherence tomography: a consensus statement of the Society of Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2014;83(4): Fearon WF, Yeung AC, Lee DP, Yock PG, Heidenreich PA. Cost-effectiveness of measuring fractional flow reserve to guide coronary interventions. Am Heart J. 2003;145(5): Botman CJ, Schonberger J, Koolen S, et al. Does stenosis severity of native vessels influence bypass graft patency? A prospective fractional flow reserve-guided study. Ann Thorac Surg. 2007;83(6): Di Serafino L, De Bruyne B, Mangiacapra F, et al. Long-term clinical outcome after fractional flow reserveversus angio-guided percutaneous coronary intervention in patients with intermediate stenosis of coronary artery bypass grafts. Am Heart J. 2013;166(1): Lai CC, Fang HC, Tsai HL, et al. Translesional pressure ratio predicts technical outcome and patency in angioplasty on outflow stenosis of hemodialysis graft. J Vasc Access. 2014;15(4): Jensen LO, Thayssen P, Thuesen L, et al. Influence of a pressure gradient distal to implanted bare-metal stent on in-stent restenosis after percutaneous coronary intervention. Circulation. 2007;116(24): Klauss V, Erdin P, Rieber J, et al. Fractional flow reserve for the prediction of cardiac events after coronary stent implantation: results of a multivariate analysis. Heart. 2005;91(2): Nam CW, Hur SH, Cho YK, et al. Relation of fractional flow reserve after drug-eluting stent implantation to one-year outcomes. Am J Cardiol. 2011;107(12): Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally nonsignificant stenosis: 5-year follow-up of the DEFER Study. J Am Coll Cardiol. 2007;49(21): Pijls NH, Klauss V, Siebert U, et al. Coronary pressure measurement after stenting predicts adverse Vascular Disease Management September

7 events at follow-up: a multicenter registry. Circulation. 2002;105(25): Golledge J, Ferguson K, Ellis M, et al. Outcome of femoropopliteal angioplasty. Ann Surg. 1999;229(1): Khashaba A, Mortada A, Omran A. Intracoronary versus intravenous adenosine-induced maximal coronary hyperemia for fractional flow reserve measurements. Clin Med Insights Cardiol. 2014;8: Lindstaedt M, Bojara W, Holland-Letz T, et al. Adenosine-induced maximal coronary hyperemia for myocardial fractional flow reserve measurements: comparison of administration by femoral venous versus antecubital venous access. Clin Res Cardiol. 2009;98(11): Wang X, Li S, Zhao X, Deng J, Han Y. Effects of intracoronary sodium nitroprusside compared with adenosine on fractional flow reserve measurement. J Invasive Cardiol. 2014;26(3): Lotfi AS, Sivalingam SK, Giugliano GR, Ashraf J, Visintainer P. Use of fraction flow reserve to predict changes over time in management of superficial femoral artery. J Interv Cardiol. 2012;25(1): Kim JE, Koo BK. Fractional flow reserve: the past, present and future. Korean Circ J. 2012;42(7): Vascular Disease Management September

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