««Push and Park»». An Alternative Strategy for Management of Embolic Complication During Balloon Angioplasty

Introduction popliteal embolectomy and the final patient was sucessfully treated with conservative management (Table Percutaneous transluminal angioplasty (PTA) is an 1). established technique in the management of arterial 5000 IU of Heparin are given routinely prior to disease. The incidence of distal embolisation in our angioplasty through the catheter and Aspirin institution during both subintimal angioplasty and 75–150 mg OD, following the procedure. This protocol transluminal angioplasty is 3.5%. This compares to is not modified following successful aspiration or recently published complication rates of transluminal pushing and parking of emboli. angioplasty of 3.7% and a 2.5% rate of occlusive An 8 French embolectomy non-tapered teflon coated complications in a larger series of 1141 patients. Concatheter is used to attempt removal of embolus by ventionally the options for embolectomy would be to aspiration in the first instance. The technique involves consider aspiration, thrombolysis or surgical readvancing the catheter over a guidewire to the level moval. We have employed an alternative technique of the embolus until free back bleeding has ceased. in the event of failure to aspirate an embolus, which Suction is then applied with the use of a 50 ml syringe. involves pushing the embolus distally. Suction is maintained whilst the catheter is moved to and fro in the artery to aid engagement of the embolic material. The catheter is then withdrawn to the sheath with constant suction maintained and finally extracted, Technique with the haemostasis valve removed to prevent dislodgement. The technique was employed in six patients (four However, in some cases the applied suction fails to male), age range 62 to 85, between February 1997 engage the embolus. In these cases when there is more and August 1999. Of the six patients, PTA was being than one runoff vessel, the technique of ‘‘push and performed for critical ischaemia in five and inpark’’ becomes applicable. The same 8F non-tapered termittent claudication in one. One thousand and catheter without the wire is used to push the embolus. twenty-seven angioplasties were performed during The favoured straight path usually lands the embolus this period. In patients with thromboembolic cominto the peroneal artery. The aim is to leave at least plications, aspiration was successful in 68% of attempts one remaining vessel with free flow. Placing the wire with the technique of push and park used in 21%. Of the remaining 11%, two patients went on to have into the artery with the poorest distal circulation may below knee amputations, one patient had a surgical allow selection of the vessel into which the embolus is pushed and has been adopted for future cases. Modifying the technique in this way would have the ∗ Please address all correspondence to: A. Higginson, Department of Radiology, Leicester Royal Infirmary, Leicester LE1 5WW, U.K. added advantage of avoiding pushing the catheter