[Vascular access-site infections in percutaneous cardiac interventions: A significant risk?] / Infection des abords vasculaires et interventions cardiaques percutanées : un risque significatif ?

Vascular access site infections are infrequent and rarely reported as a potential complication of percutaneous cardiac intervention. A case of access site infection is reported with a literature review. Femoral access is mainly concerned in some circumstances: delayed sheath withdrawal, vascular complications (hematoma, false-aneurysm, arteriovenous fistula), or use of hemostatic closure device. These infectious complications are always serious requiring medical and surgical treatment and potentially associated with life-threatening complications. Preventive measures should be applied in order to reduce the risks: optimisation of femoral punctures with the support of echography guidance, avoid a new puncture in a area with hematoma, femoral angiographic evaluation and strict aseptic precautions with vascular closure devices, and obviously preferential choice of radial access.

Cryopreserved arterial allografts used for the treatment of infected vascular grafts.

In this study, 18 patients (17 men and 1 woman; mean age 61 years) with a previously infected vascular graft underwent vascular reconstruction with cryopreserved arterial allografts. Treatment consisted of first total (n = 11) or partial removal (n = 7) of infected prosthetic grafts. Revascularizations were aortoaortic (n = 2), aortobifemoral (n = 8), aortounifemoral (n = 3), femorofemoral (n = 2), iliofemoral (n = 1), or femoropopliteal (n = 2) bypasses. Four patients died postoperatively (22%)-one of septic necrosis of the allograft, one of septic rupture of the aortic anastomosis of a previous bypass, one of multiorgan failure, and one of mesenteric infarction. One allograft occluded within 30 days (5.5%), leading to an above-knee amputation. In the remaining patients, routine arteriography or duplex scan showed patent allografts. For the 14 survivors, the mean follow-up period was 20 months (range: 1-45 months). Two patients died-one of septicemia not related to the allograft, and one of multiple organ failure. Among the 12 survivors, 3 patients with non-ABO-compatible allografts developed different types of long-term alterations. One patient had a hemorrhage due to femoral allograft rupture at 45 days, and two patients had aortic allografts dilatation with mural thrombus, necessitating a prosthetic replacement in one patient. Cryopreserved allografts used for the treatment of infected vascular graft are useful in selected cases, although they are not totally resistant to infection. Patients should be followed closely to detect significant long-term alterations of the allografts.

Are femoro-infrapopliteal bypasses worthwhile for limb salvage?

OBJECTIVE: This study was performed in order to determine if: 1-- femoral bypasses ending below the popliteal artery are justified in aged patients or in patients with poor general conditions, 2-- if the use of prosthetic material is justified when no vein is available, 3-- if reintervention is beneficial in case of bypass occlusion. EXPERIMENTAL DESIGN: Retrospective study of 162 infrapopliteal bypasses followed during 1 to 12 years (mean: 1.5). SETTING: Vascular Surgery Department of the University Hospital Henri Mondor based in a suburb of Paris, France. PATIENTS: All patients who underwent a femoral bypass ending below the popliteal artery for limb salvage from January 1984 to December 1995. INTERVENTION: These bypasses were performed with a vein in 131 cases and with a PTFE graft (with or without distal cuff) in 31 cases. MEASURES: All patients were followed with clinical evaluation and duplex scan. Primary and secondary patency, limb salvage and patient survival were studied. The survival rates at 1 and 5 years were 87+/-3.8% and 66+/-9.6% respectively. Preoperative mortality was 7.4%. Renal insufficiency requiring dialysis, not age over 80, was associated with high perioperative mortality. RESULTS: The primary patency rates of the total series at 1 and 5 years were 55 and 35% respectively for the total series. For venous bypasses, it was 58 and 37% while for prosthetic bypasses, it was 49 and 15%. The secondary patency rates at 1 and 5 years were 67 and 46% for the total series. For venous bypasses, it was 70 and 49% and for prosthetic bypasses, it was 53 and 21%. Limb salvage rates at 1 and 5 years were 65 and 61% for the total series, 73 and 65% for venous bypasses and 48 and 41% for prosthetic bypasses. CONCLUSION: 1-- Femorotibial or peroneal bypasses are worthwhile for limb salvage even in aged patients but renal insufficiency requiring dialysis may justify primary amputation. 2-- If no vein can be used, prosthetic or composite bypasses should be performed because they are associated with a 41% limb salvage rate at 5 years. 3-- If thrombosis occurs, the increase of patency after re-operation is 12% in case of venous bypass and 6% in case of prosthetic bypass.

Some popliteal aneurysms are congenital.

Although the majority of popliteal aneurysms are of atherosclerotic origin and are discovered in patients aged more than 50, the aetiology of a small minority may be attributed to arterial trauma, septic disruption, Behcet's disease, a medial fibromuscular dysplasia, or popliteal entrapment. The aim of this study was to propose a possible congenital origin for popliteal aneurysms without evidence of any other aetiology. A retrospective review of five younger patients (aged 20-45 years) with seven non-atherosclerotic popliteal aneurysms was performed. In patient nos 1 and 2, histological examination showed that the arterial wall had been replaced by an abundant collagenic tissue. After replacement by a saphenous bypass graft, these patients did well with a follow-up ranging from 1 to 15 years. Patient no. 3 was not operated on because of a symptomless occlusion of the tibial and peroneal arteries, and remains well 10 years later. Patients nos 4 and 5 were treated with a saphenous bypass graft. The last patient also had associated bilateral congenital anomalies of the division of the popliteal arteries. In the absence of any evidence of any classical aetiology, particularly fibromuscular dysplasia and popliteal entrapment, a congenital aetiology is proposed in aneurysms diagnosed in younger patients. The complex composition of the popliteal artery, being composed by an association of three original segments, may induce a fragility of the arterial wall that may be responsible for aneurysmal deterioration as well as abnormal branching or popliteal artery entrapment. These aneurysms are associated with the same risk of thrombosis as atherosclerotic aneurysms and therefore, they should be subjected to the same therapeutic considerations.

Simultaneous endoluminal dilatation and conventional surgery. Importance of programmed revascularization of the legs. / Dilatation endoluminale et chirurgie conventionnelle simultanées. Intérêt dans les revascularisations programmées des membres inférieurs.

OBJECTIVE: evaluate the benefit of synchronous arterial reconstruction and endoluminal balloon dilatation for occlusive arterial disease during non-urgent procedures. METHOD: late results of forty arterial reconstructions combining open surgery with simultaneous endoluminal dilatation have been reviewed. Balloon dilatation was performed on iliac (N = 18), femoral (N = 18), popliteal (N = 3) and infra-popliteal arteries (N = 2). Reasons were rapidity in 31 cases, local reasons in five cases (such as brievity of available vein for bypass), heavy operative risk in two cases and partial failure of transluminal angioplasty in two cases. RESULTS: during the first post-operative month, there were one death (due to sepsis) and two reocclusions (one of the dilated artery and the other of the bypass). They were successfully reoperated. At the moment of the study, the mean follow-up being thirty months, seven patients are deceaded (six of them from intercurrent disease), one has been amputated, three suffer intermittent claudication and twenty-nine are cured (but eight of them have been reoperated). CONCLUSION: synchronous arterial reconstruction and transluminal dilatation are a good option in case of multiple arterial occlusive disease particularly in poor risk patients and when inflow or outflow of bypasses should be improved. Associated balloon dilatation is very useful in case of too short vein graft or arterial stenosis due to a clamp injury. Nowadays in our department, these combined procedures are more and more frequent One stage procedure is associated with less complications, shorter length of hospitalization and lower cost.

Management of radiation-induced occlusive arterial disease: a reassessment.

BACKGROUND: The goal of this study was to evaluate the operative hazards, therapeutic procedures, and late results of arterial reconstruction for radiation-induced occlusive disease. METHODS: Twenty-five patients were referred to our institution for radiation-induced occlusive arterial disease. Group 1: carotid artery stenosis or occlusion was encountered in seven patients. The nine procedures employed included percutaneous transluminal angioplasty (PTA) (n = 2), carotid endarterectomy (n = 3), vein or prosthetic bypass (n = 4). Group 2: four patients presenting with subclavian and axillary artery occlusion were treated with a common carotid to brachial artery vein bypass, one after unsuccessful PTA. Group 3: Thirteen patients had aorto-iliac occlusion. Initial management included medical treatment (n = 1), PTA (n = 2), aorto-bifemoral bypass (n = 4), aortofemoral and iliofemoral bypass (n = 1 each), axillofemoral bypass (n = 3), femorofemoral bypass (n = 1). Group 4: One patient had femoral artery occlusion treated with PTA. RESULTS: Group 1: One of two PTA was successful. Endarterectomy or bypass were successful in all cases. One late vein bypass stenosis was treated by venous patch angioplasty. Group 2: All vein bypasses were successful. Group 3: Limb salvage was achieved in all patients but eight required repeat operations for prosthetic sepsis (n = 3), restenosis (n = 3), or thrombosis (n = 12). Two patients died of late sepsis. Group 4: Outcome after PTA was successful. CONCLUSIONS: 1) Surgery for radiation-induced arterial lesions is difficult because of arterial, periarterial, and cutaneous sclerosis. Some patients, however, are amenable to PTA or endarterectomy. When bypass is necessary, anastomosis should be performed in healthy arteries, for instance, the thoracic aorta for the proximal anastomosis, or the brachial artery approached through a lateral mid-arm incision. 2) The risk of early or late graft infection is enhanced by the presence of tracheostomy, colostomy, or ureterostomy and by repeat operation for thrombosis. PTA, endarterectomy, or vein bypass should be preferred whenever feasible. When prosthetic material is unavoidable, prevention of infection should include the use of omentoplasty, remote bypass, antibiotic-bonded grafts or, in the case of major sepsis, allografts. 3) As restenosis remains a frequent complication, annual clinical and Duplex-scan surveillance is mandatory.

Polytetrafluoroethylene grafts for carotid repair.

Polytetrafluoroethylene grafts are well established for bypassing occlusive disease in the lower limb but there are few reports which deal with the long-term results of such grafts in the neck. The present study was undertaken to evaluate the immediate and long-term results of polytetrafluoroethylene grafts for carotid repair. Between 1982 and 1991, 591 carotid operations (mostly endarterectomies) were performed by the authors. In 32 cases a polytetrafluoroethylene graft was used to replace (n = 12) or to bypass (n = 20) a stenotic lesion of the internal carotid artery. Postoperative angiography was obtained in all patients and the follow-up extended from 1 month to 9 years (mean 30 months) with clinical and duplex scan surveillance. There were no deaths within the first postoperative month. There was one acute postoperative stroke (3%) caused by plaque dislodgement and one symptomless occlusion demonstrated by routine angiography. During follow-up, seven patients died from other causes. No patient developed new neurological symptoms but routine duplex assessment showed one symptomless graft occlusion. The cumulative survival rate was 96% at 1 year and 91% at 4 years. The cumulative primary patency rate was 93% at 1 month, 89% at 1 year and 89% at 4 years. In specific situations polytetrafluoroethylene grafting is an adequate alternative to carotid endarterectomy but is not recommended by the authors as a routine procedure because of its occlusion rate (> 6.2%).

[Collective self-evaluations in vascular surgery: indispensable lever for optimizing results]. / Les auto-évaluations collectives en chirurgie vasculaire. Indispensable levier de l'optimisation des résultats.

The quality of the results obtained for a given surgical team cannot be guaranteed by simply applying the recommendations of scientific research and consensus conferences. Self-evaluations is as important as continuous training. It is essential for each surgical team to regularly evaluate its results and compare them with those published in the literature in order to make necessary improvements. Lessons learned from mortality-morbidity sessions studying complications case by case should be completed with an annual assessment of complications for each group of operations, first because knowledge of results is required before modifications in technique and organization can be indicated and secondly because the discussion of all the results with the entire surgical team, including both medical and paramedical personnel, offers the best means of optimizing competency and team cohesion and effort. Useful means include: 1) self-assessment software similar to those used for MSI, 2) a requirement for self-assessment before annual fund allocations, 3) that the self-assessments remain the property of the surgical teams in order to avoid missing the goal which is to optimize surgical indications and results.

[Impregnated polyester prostheses: a theoretical advantage]. / Prothèses en polyester imprégnées: un avantage théorique.

Leak-proof polyester grafts impregnated with collagen, gelatine or albumin are routinely used in vascular surgery. Theoretically, there are several advantages: no need for pre-coagulation, reduced operation time and graft manipulation, less blood loss during the operative period, better healing with a potentially greater resistance to infection. We analyzed all the publications in scientific journals to verify whether these theoretical advantages are validated by clinical trials. There have been 12 non-comparative series reporting favourable results but the lack of control groups makes it difficult to draw conclusions. Five comparative series with random assignment of patients have been reported. None of these series showed a substantial benefit from impregnation. Thus the use of an impregnated polyester graft would not appear to be justified for routine standard aorto-iliac surgery. Conversely, although no evidence has been provided by a comparative study, the major risk of haemorrhage in procedures such as extra-corporal circulation, the thoracic or abdominal aorta and in patients with a coagulation disorder, impregnated graft probably constitute an important progress.

[Antibiotic-impregnated prostheses: eclectic indications]. / Prothèses imprégnées d'antibiotiques: des indications éclectiques.

OBJECTIVE: Infection is a major complication in vascular stents. Stents impregnated with gelatine and dipped in Rifampicin have been shown to resist methicillin-resistant Staphylococcus aureus in both animal experiments and in man. It has been suggested that all aorto-ilio-femoral stents should be treated. To evaluate this method, we reassessed all stent infections observed in our patients who had undergone revascularization of the lower limbs from January 1985 to 1994. We excluded stents implanted for ruptured aneurysms or implanted in patients with a past history of local infection on vascular stents. RESULTS: The rate of septic complications observed during the first year was 1% for all patients in the series, 0% for aorto-aortic and aorto-biiliac stents and 0.7% for aorto- bifemoral stents. These rates are similar to those reported in the multicentric study directed by Goeau Brissonière using antibiotic impregnated stents. The extra cost involved in using such stents for aorto-ilio-femoral revascularization was estimated in this series at 2,180,000 Francs. The costs resulting from the three infections was estimated at 960,000 Francs. CONCLUSION: Based on the findings in this series, antibiotic impregnated stents should be indicated only in selected patients due to the extra cost: past history of local infection, ruptured aneurysms, femoro-tibial stents, cross or axillo-femoral revascularization for which the rate of stent infection is 6.3 - 3.2 and 1.4%, immunodeficient patients, multiple reoperations, post-irradiation arteritis and situations known to involve major risk of infection.

[Severe limb ischemia due to iatrogenic trauma]. / Ischémies sévères des membres dues à des traumatismes iatrogènes.

OBJECTIVES: Assess the frequency, severity and technical problems raised by iatrogenic trauma to the arteries. METHOD: A retrospective study of 45 cases of iatrogenic arterial trauma treated over a 25-year period was studied. RESULTS: The most frequent cause was arterial catheterization (n = 32 including 24 of the lower limbs and 8 for the upper limbs) performed for arteriography (n = 16), coronarography (n = 13) or endovascular therapy (n = 3). Thrombectomy was performed in 24 cases, bypass in 4 and endarterectomy in 4. Post-operative period was uneventful in all except two fatal cases. CONCLUSION: In most cases, iatrogenic arterial trauma can be avoided with proper technique. Prognosis is highly dependent on early care.

[False anastomotic aneurysms after aorto-femoral prosthesis. Detection, prevention and treatment]. / Faux anévrismes anastomotiques après prothèse aorto-fémorale. Dépistage, prévention et traitement.

OBJECTIVE: The aim of this study was to evaluate screening, prevention and treatment of false anastomotic aneurysms (FAA). METHOD: A retrospective analysis of 95 FAA observed in 72 patients (67 males, 5 females, age range 48 to 93 years was conducted. Mean delay to onset was 7.5 years. RESULTS: Diagnosis was made on the basis of imaging evidence using, since 1978, duplex-scan: 8/15 FAA of the aorta, 4/5 FAA of the iliac arteries and 35/75 FAA of the femoral arteries. Treatment was always difficult due to atherosclerosis. The greatest difficulties were encountered in aortic FAA with 1 death due to septic rupture, 1 nephrectomy by ureteral fistula and 1 graft sepsis successfully treated with an allograft. There were 2 deaths in the iliac FAA, 1 due to ureteral fistula and 1 due to heart failure. For femoral FAA, there were 3 deaths (cerebral hemorrhage, graft sepsis and renal failure after acute aortic thrombosis). Long term results showed 6 recurrent femoral FAA which were reoperated successfully. CONCLUSION: FAA complicates 2 to 5% of graft procedures and can lead to death and amputations: 1.) Clinical surveillance and regular duplex-scan examinations are essential: the diagnosis should also be entertained in case of digestive hemorrhage. 2.) The threshold of dilatation which suggests the need for surgical repair would appear to be a two-fold dilatation but for the aorta, localized dehiscence requires surgery. 3.) A graft procedure is usually used, stents can by used for end-to-end aortic or iliac anastomoses. 4.) Since FAA remains a risk after graft, revascularization should be entertained when other methods have failed. 5.) Patients should be informed of the risk and of movements to avoid in case of femoral anastomoses and also of required regular checkups.

Conventional versus endovascular surgical procedures: a no choice option.

The on-going debates on the competitiveness of endovascular and conventional surgery in the treatment of peripheral occlusive vascular diseases are justified by the fact that endovascular procedures are associated with a lower mortality and morbidity, require a shorter hospital stay, and are less costly than conventional surgery. However, scientific and economic comparisons between the two techniques are difficult because they cannot strictly be applied to the same patients. Patients who may benefit from endovascular surgery are generally at an earlier stage of the disease, they have claudication and short stenoses or occlusion. On the other hand, patients who present with severe claudication or critical ischaemia, in most cases, have long occlusions, multiple segmental disease and often require conventional surgery.

Iliac and femoropopliteal lesions: evaluation of balloon angioplasty and classical surgery.

PURPOSE: The purpose of this study was to compare the characteristics of patients treated for atherosclerotic disease of the lower extremities with balloon angioplasty (BA) or classical surgery (CS) and to assess the outcome of both techniques. METHODS: The records of 1364 patients who were treated with BA or CS for chronic lower limb ischemia between 1986 and 1993 were analyzed. Demographic features of patients, immediate and long-term survival, patency, and amputation rates were compared in both groups according to the level of the revascularization (iliac or femoropopliteal). RESULTS: Patients undergoing BA were slightly younger (62.3 years versus 65.9 years for CS group; p = NS) and demonstrated symptoms consistent with less severe atherosclerotic disease (81% claudication in the BA group versus 48% in the CS patients; p < 0.001). At 30 days post-treatment in the BA and CS groups, respectively, there were 0.7% and 4% deaths (p < 0.01); 13% and 6% primary failures (p = 0.013); 13% and 6% secondary failures (p = 0.01); 0.3% and 12% general complications (p = 0.001); and 3% and 8%, nonvascular complications (p = 0.007). At the iliac level, in the angioplasty (n = 134 limbs) and surgery (n = 721 limbs) groups, respectively, the mean age was 57.6 and 63.7 years (p < 0.01), and claudication was present in 91% and 72%. Perioperative mortality was 0% and 1.9%. The 4-year survival rates were 95% and 88%; patency was 70% and 79%; and the amputation rates were 0% and 5%. At the femoropopliteal level, in the angioplasty (n = 138 limbs) and surgery (n = 656 limbs) groups, respectively, the mean age was 67.8 and 66.8 years (NS), and claudication was present in 69% and 28%. Perioperative mortality was 0.9% and 5.5%. The 4-year survival rates were 95% and 78%; and patency was 44% and 65%. At 2 years, the amputation rates were 6% and 12%. CONCLUSIONS: Patients treated by BA were younger, especially in the iliac group, and had less symptomatic lesions than patients treated with surgery. Surgery achieved a better long-term patency at the cost of a higher immediate complication rate and mortality. Whenever technically feasible, BA may be the better choice for initial therapy in appropriate patients suffering from chronic lower limb ischemia.

[Surgical treatment of sclerotic arterial diseases of the lower limbs]. / Traitement chirurgical des artériopathies scléreuses des membres inférieurs.

Among arterial reconstruction procedures, thromboendarterectomy has progressively left place to prosthetic grafts for aorto-iliac surgery. At infra-inguinal level, inversed or in situ venous grafts allow distal revascularisations down to the foot. Lumbar sympathectomy keeps some indications. Indications depend upon the level of arterial obstruction, the symptoms, and the operative risk of the patient. At aorto-iliac level surgery provides excellent results; indications for proximal surgery are large; operative risk is the main limiting factor. At infra-inguinal level surgery is well tolerated but permeability rates are not as good as with aorto-iliac surgery; distal surgery is appropriate only is case of critical ischaemia, when everything must be done for limb salvage.

[Patients operated on for aneurysms of the abdominal aorta: risk factors and survival]. / Anévrismes de l'aorte abdominale opérés: facteurs de risque et survie.

Patients requiring radical cure of an aneurysm of the abdominal aorta often have associated conditions increasing the risk of peri-operative complications and immediate or short-term mortality. Detecting such associated lesions is thus of major importance to adapt patient management and treatment strategy. We assessed the following parameters associated with increased risk of peri-operative death in a series of 418 patients who underwent elective surgery for aneurysms of the abdominal aorta between 1986 and 1994: chronic renal failure (with or without dialysis), clinically apparent coronary artery disease, age over 75 years, defective left ventricular function. The effect of the characteristics of the aneurysm on immediate survival was also assessed. Aneurysm larger than 6 cm extending to the hypogastric artery had a higher operative risk. Post-operative survival was 96.5% at one month, 90% at one year and 87% and 69% at 2 and 5 years respectively. The predominant causes of death late in the post-operative period were vascular disease (coronary or neurologic) and cancer. Complications related to the operation were rare (1.5%). In conclusion, detection of operative risks allows 1) better patient selection for surgery, 2) adopting appropriate measures when the indication for surgery is retained, 3) establishing a follow-up and a screening protocol for detecting factors causing late deaths.

Thrombogenicity of an elastomer-coated aortofemoral Dacron prosthetic graft in humans.

To determine the potential benefit of Dacron prostheses impregnated with silicon polymer, an elastomer-coated prosthetic graft (Intervascular [I]) was implanted in 30 patients with aortic occlusive arterial disease or infrarenal abdominal aortic aneurysm. These patients were compared with two other groups who underwent vascular reconstruction with either a knitted double-velour prosthesis (Meadow [M] or a knitted prosthesis (Bard-USCI [U]). The different prostheses were randomly allocated just prior to their insertion. Average blood loss was 1063.33 +/- 1065.69 ml for the I group, 888.33 +/- 575.85 ml for the M group, and 908.33 +/- 471.80 ml for the U group (NS). The duration of the operation was 160 +/- 56 minutes for the I group, 142 +/- 37 minutes for the M group, and 153 +/- 65 minutes for the U group (NS). The average follow-up was 12 months. As calculated by the actuarial method, primary patency at 36 months was 71.5% for the I group, 100% for the M group, and 98.2% for the U group (p < 0.001). Secondary patency was 73.7% for the I group and 100% for the M and U groups, respectively (p < 0.001). This study shows that the thrombogenicity of the elastomer-coated aortofemoral vascular prosthetic graft was significantly higher than that of the two other prostheses. Increased intraoperative blood loss and longer duration of operation were related to the aortic abnormality being treated (aneurysm or occlusion) rather than to the type of prosthetic graft being used.

Surgical transluminal femoropopliteal angioplasty: multivariate analysis outcome.

PURPOSE: The purpose of this study was to determine the efficacy of femoropopliteal transluminal angioplasty performed in the operating room by vascular surgeons and the factors that might influence outcome. METHODS: The clinical, biologic, and angiographic, findings of 103 consecutive transluminal angioplasties performed in the operating suite in 95 patients for occlusive disease of the femoral or popliteal arteries were analyzed. With each variable, patency was compared according to the log rank test, and a Cox multivariate analysis was applied to the statistically significant variables. RESULTS: Local, general, and vascular complications occurred in 2.8%, 0.9%, and 2.8% of cases, respectively. The cumulative patency rate was 77.9% +/- 3.9% at 1 month, 59.8% +/- 5.35% at 1 year, and 51.3% +/- 6.15% at 2 years, including early failures (20.7%). Of 11 preoperative factors studied, only the stenotic or occlusive character and the length of the lesion were shown to be statistically significant (p < 0.001 and p < 0.01, respectively). The constructed mathematic Cox proportional hazards regression model allowed definition of the probability of success according to four groups, based on angiographic findings. At 2 years the probability of success was 80% in patients with stenosis less than 2 cm long, 62% in patients with stenosis greater than 2 cm, 42% in patients with occlusion less than 2 cm long, and 20% in patients with occlusion greater than 2 cm long. CONCLUSION: Transluminal femoropopliteal angioplasty may be performed safely by vascular surgeons in the operating room. Based on this model, proper selection of patients who might best benefit from transluminal angioplasty for femoropopliteal disease may be made.