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Poster session 25: Peripheral arterial disease
P25.01
Outcomes of percutaneous transluminal angioplasty (PTA) in elderly with ischemic
diabetic foot
Cesare Miranda, Azienda Ospedaliera S.Maria Degli Angeli, Pordenone, Italy
Matteo Cassin, Azienda Ospedaliera S.Maria Degli Angeli, Pordenone, Italy
Riccardo Neri, Azienda Ospedaliera S.Maria Degli Angeli, Pordenone, Italy
Roberto Da Ros, Hospital San Polo, Monfalcone, Italy
Giorgio Zanette, Azienda Ospedaliera S.Maria Degli Angeli, Pordenone, Italy
Background: Successful revascularization reduces the major amputation rate in diabetic
patients presenting with critical limb ischemia (CLI) . AIM To evaluate the outcomes of
percutaneous transluminal angioplasty ( PTA) in elderly with ischemic diabetic foot (DF).
Materials and methods: We have retrospectively selected all elderly diabetic patients ( ≥65
years) admitted in our two foot centres in 2 consecutive years with diabetic foot and a
diagnosis of critical limb ischemia (CLI), in according to the TransAtlantic Inter-Society
Consensus (TASC 2007) and who underwent PTA. Treatment strategy was decided by a
team of diabetologist, interventional cardiologists and vascular surgeon.From January 2012
to December 2013 a total of 46 patients were included. Mean (SD) age of the patients was
78.6, (6.37) years, and 31 patients (67.3%) were male.
Results: PTA was performed in 67 limbs, the treated arteries were localized below the knee
( 56.7%), above the knee ( 28.3%), being the remaining (14.9%) treated at both levels, the
limb salvage rate was 97% after a mean follow-up of 267.5 ±145.1 days, minor amputations
rate was 41.3 %, target-vessel re-stenosis had occurred in 19 2% of non-amputated limb,
two patients (4.34%) had died because conditions unrelated to PTA and nine patients (
19.5%) did not heal .
Conclusions: In our selected patient population with diabetic foot and critical limb ischemia
a successful endovascular procedure led to a high percentage of limb salvage and confirms
the positive role of PTA-First Approach for revascularization of elderly with CLI and DF.
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Page 1 of 11
P25.02
Crural percutaneous transluminal angioplasty in ischemic diabetic foot ulcera: a
retrospective analysis
René Scheer, Ziekenhuisgroep Twente, Almelo, Netherlands
Jaap van Netten, Ziekenhuisgroep Twente, Almelo, Netherlands
Robbert Meerwaldt, Medisch Spectrum Twente, Enschede, Netherlands
J van Baal, Ziekenhuisgroep Twente, Almelo, Netherlands
M. Kraai, Ziekenhuisgroep Twente, Almelo, Netherlands
Aim: To evaluate the results of crural percutaneous transluminal angioplasty (PTA) in
patients with ischemic diabetic foot ulcera in our dayly practice. `
Methods: A retrospective study was conducted at two general hospitals, between January
2012 and November 2014. Data was retrieved from patient records. All patients with a foot
ulcer and diabetes, who underwent an infrapopliteonal PTA were included.
Results: A number of 83 patients was included. Patients were mostly male (72%) with a
mean age of 74.2 years (SD 11.1). Stage C (56.6%) and grade 2 (47%) ulcera were most
common according to the Texas University wound classification. Mean toe pressure was 29
mmHg (SD 22). The mean interval between diagnosis and PTA was 1.3 months (SD 2.7). A
number of 24 ulcera (30.1%) healed and 34 (41%) amputations were performed. The mean
time of follow-up was 10.9 months (SD 10.4).
Conclusion: The current series is one of the largest that is published by centers that are not
specialised in either endovascular or bypass treatment. The results of this study are a useful
addition to the ongoing debate on the most effective vascular treatment for ischemic diabetic
foot ulcers.
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Page 2 of 11
P25.03
Posterior tibial artery recanalization by “pedal-plantar loop technique”: a case report
in diabetic patient with infective necrosis foot
Roberto De Giglio, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Gianni De Angelis, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Anna Socrate, Azienda Ospedaliera Legnano, Legnano, Italy
Teresa Mondello, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Ilaria Formenti, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Sara Lodigiani, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Giacoma Di Vieste, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Gianmario Balduzzi, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
A male diabetic patient of 65 years is reported who presented with infective necrosis of
second toe (III D according to TWC) and initial lesion of left hindfoot (I C). Transcutaneous
oximetry (TcPO2) at the dorsum of the foot was TcPO2 = 37 mmHg in the presence of mild
oedema. After amputation of the second toe necrotic, the wound was left open and
underwent revascularization of the left lower. The first step was to have an anterograde
approach through common artery by using a 11 cm long 5F introducer sheath. The
angiographic study shown the patency of femoro-popliteal artery, while the tibio peroneal
trunk, was steno-occluded, the, posterior and the peroneal arteries were occluded at ostium
and the pedal-plantar loop and dorsal pedis artery were open. The hindfoot was not
vascolarized. By using a light support straight, 0.14” wire and, as support, a compatible
balloon, we fail in overcome the distal posterior tibial artery and enter the plantar common
artery. To avoid dissection, we placed an other wire in lateral plantar artery through deep
perforanting artery by using the “pedal-plantar loop technique”. The rendez-vous, in, lateral
plantar artery guaranteed the intravascular position of the wire.
So we made an anterograde revascularization of lateral plantar artery, posterior tibial artery
and tibio- peroneal trunk.
Final angiographic control documented the posterior circulation (posterior tibial artery and
lateral plantar artery) and medial calcaneal branches patency.
The initial lesion of left hindfoot healed spontaneously, while in the forefoot was removed all
gangrenous tissue and was necessary the amputation of the second and the third toe with
metatarsal head (patient refused transmetatarsal amputation). In this clinic case this
technique of revascularization extreme allowed the limb salvage in the ischemic foot.
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Page 3 of 11
P25.04
Postoperative revascularization by percutaneous transluminal angioplasty after free
flap reconstruction of diabetic foot ulcer
Donghyeok Shin, Konkuk University Medical Center, Seoul, Korea, South
Wonchul Choi, Konkuk University Medical Center, Seoul, Korea, South
Aim: Approximately 50% of diabetic foot ulcer patients have peripheral arterial disease
clinically and it is one of the major risk factors for free flap failure. Revascularization should
be, essential, especially, when free flap surgery was planned in these patients. After
successful re-establishment of circulation, what can we do when the active pumping from
recipient vessel after identifying it and donor flap harvesting? Nobody could guarantee the
flap survival with postoperative percutaneous transluminal angioplasty (PTA). We report two
cases of successful free flap reconstruction of diabetic foot ulcer through postoperative
revascularization despite of intraoperative arterial circulatory compromise.
Methods: Case 1) A 74-year-old female patient had necrotic diabetic foot ulcer on her 3rd,
4th toe. We performed anterolateral thigh free flap and noticed circulatory compromise in
dorsalis pedis artery. After completion of operation, we revascularized the vessel with PTA
13 hours after the operation(Fig. 1).
Case 2) A 74-year-old male patient had chronic diabetic foot ulcer on his right big toe for
over 5 months. We performed anterolateral free flap and noticed the abrupt loss of active
pumping from, 1st metatarsal artery during the operation. We decided to revascularize the
vessel via PTA immediately after the operation.
Results: Both PTA were successful. The patient in case 1 showed partial necrosis, however,
the defect could be covered with skin graft easily. The patient in case 2 showed complete
flap survival.
Conclusion: When diabetic foot ulcer patients present unexpected abrupt arterial
insufficiency from recipient vessel during free flap surgery, postoperative revascularization
with PTA can be helpful to reverse the circulatory compromise and boost the flap survival.
Fig. 1. (A) Preoperative angiogram showing the patent dorsalis pedis artery. (B)
Postoperative angiogram before percutaneous transluminal angioplasty (PTA) showing total
occlusion of the dorsalis pedis artery (black arrows). (C) Postoperative angiogram after PTA
showing the revascularized dorsalis pedis artery (black arrows) and excellent blood flow into
the flap (white arrow).
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Page 4 of 11
P25.05
Angioplasty of peripheral arteries for diabetic and non-diabetic patients: Can we rely
on balloon angioplasty with limited use of stents?
Konstantinos Papazoglou, Aristotle's University of Thessaloniki, Thessaloniki, Greece
Konstantinos Konstantinidis, "Kyanous Stavros" EUROMEDICA Clinic, Thessaloniki, Greece
Maria Mitka, "Kyanous Stavros" EUROMEDICA Clinic, Thessaloniki, Greece
Aim: To report our experience of the treatment of patients (diabetics and non-diabetics)
using strictly endovascular techniques (simple balloon angioplasty with or without stenting)
and the results of 6 to 30 month follow-up.
Methods: During the period of April 2009 to April 2011, 175 patients (133 males and 42
females) underwent endovascular procedures for the treatment of various types of PAD.
Patients were divided in two main groups regarding the presence (Group A) or not (Group B)
of concomitant type-B Diabetes mellitus. Simple balloon angioplasty was the “first choice
approach” for every patient using different type of balloons depending on vessel’s diameter
and lesion’s length. Whenever there was a case of surgical debridement or amputation of
any kind was needed, that was performed following revascularization based on clinical and
angiographic condition. Patients are followed for at least 24 months and reoperations were
performed whenever needed. Stenting was a “second option” only for cases of dissection or
significant restenosis, reserved mainly for the cases of reoperation.
Results: Rutherford clinical classification for both groups pre- and post-operatively are
shown in the table where improvement in clinical condition following intervention is clearly
demonstrated. During the 2 year follow up 24 patients required 33 re-interventions: 27 reinterventions for 17 (26.6%) of the diabetic patients (Group A) and 7 re-interventions for 6
(8.1%) of the non-diabetics (Group B). A total of 211 procedures were performed for both
groups, 189 (89.57%) of which consisted of balloon angioplasty (BA) alone while 22
(10.43%) procedures required additional stenting (BAS).
Conclusions: Endovascular treatment of PAD could be equally effective in diabetics and
non-diabetics, even without the use of elaborate techniques. Consistent follow-up is
necessary in order to obtain long-term results.
Rutherford
classification
CLASS 0
CLASS 1
CLASS 2
CLASS 3
CLASS 4
CLASS 5
CLASS 6
Group A (Diabetics)
Pre – op
Post – op
(n) (%)
(n) (%)
-------n=6, (8.3%)
-------n=23 (32.0%)
n=7, (9.4)
n=19 (26.4%)
n=21 (29.2%)
n=23 (32.0%)
n=13 (18.2%)
n=1, (1.3%)
n=10 (14.0%)
-------n=21 (29.2%)
--------
Group B (Non-Diabetics)
Pre- op
Post-op
(n) (%)
(n) (%)
------n=13 (12.63%)
------n=50 (48.54%)
n=13 (12.63%)
n=21 (20.38%)
n=43 (41.74%)
n=18 (17.48%)
n=13 (12.63%)
n=1, (0.9%)
n=15 (14.56%)
------n=19 (18.44%)
-------
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Page 5 of 11
P25.06
Distal bypass surgery: An unused tool in the endovascular era?
Arkeliana Tase, Watford Hospital, Hertfordshire, United Kingdom
Mustafa Halawa, Watford Hospital, Hertfordshire, United Kingdom
Raveena Ravikumar, Watford Hospital, Hertfordshire, United Kingdom
Aims: Arterial bypass surgery remains the gold standard treatment in chronic limb
ischaemia. Recently, there has been a trend towards, endovascular treatment for limb
salvage, both as primary and as an adjunct for failing grafts. The aim of this study is to
review the results of femoro-BK popliteal/distal bypass procedures carried out between Jan
2010 and Dec 2013 performed by a single surgeon.
Method: Retrospective review study of prospectively collected data. All patients that
underwent femoral –BK popliteal/distal bypass between Jan 2010 and Dec 2013 were
included. Demographic data was collected. The primary outcomes were graft patency and
limb salvage rates. The secondary outcome was 30 day mortality.
Patients were followed up in the vascular clinic. Graft patency was assessed by dupplex
scan as per protocol at 3, 6 and 12 months.
All cases of stenosis or occlusion were recorded. Patients found to have graft stenosis were
discussed at the vascular MDT meeting and considered for angioplasty. Rates of successful
angioplasty were recorded. Also, major, limb amputation (BKA, AKA) rates and 30 day
mortality were recorded.
Results: During this time 25 patients (20 male, 5 female) underwent 29 femoral-distal
bypass procedures. They had a median age of 76 yrs (47-90 yrs). 15 (60%) were diabetic
and 18 (72%) had IHD. 24 (96%) patients had tissue loss as ulcers or gangrene. All Duplex
scans were reviewed. In all cases where stenosis was found patients underwent angioplasty.
Two (7%) grafts were found to be occluded at the first scan post op. At 3 6 and 12 months,
these rates were 6 (21%), 7 (24%) and 8(28%) respectively. (Tab 1)
6 patients with graft stenosis underwent angioplasty 5 of which were successful in graft and
limb salvage. 5 patients (17%) underwent amputations (2 BKA, 3 AKA): 1 following the failed
angioplasty, and 4 following total graft occlusion.
Graft patency rate was, 93%, 76% and 72% at 1, 6 and 12 months respectively. Limb
salvage rate was 93% and 83% at 30 days and 1 year respectively. The 30 day mortality
was 7% (2).
Conclusions: Despite widespread use of angioplasty, distal bypass surgery still plays an
important role in limb salvage in diabetic patients with PVD. Duplex surveillance is essential
to save failing grafts.
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Page 6 of 11
P25.07
Improved foot salvage through pedal bypasses and pedal arch angioplasty
Elias Khalil, King's College Hospital, London, United Kingdom
Leslie Fiengo, King's College Hospital, London, United Kingdom
Roberta Brambilla, King's College Hospital, London, United Kingdom
Hani Slim, King's College Hospital, London, United Kingdom
Hiren Mistry, King's College Hospital, London, United Kingdom
Domenico Valenti, King's College Hospital, London, United Kingdom
Raghvinder Gambhir, King's College Hospital, London, United Kingdom
Michael Edmonds, King's College Hospital, London, United Kingdom
Hisham Rashid, King's College Hospital, London, United Kingdom
Introduction & aim: Both aggressive pedal arch angioplasty as well as pedal bypasses has
been used as revascularization methods in the treatment of patients with ischemic diabetic
foot. The aim of this research is to evaluate the outcomes of both modalities.
Methods: A retrospective analysis was done of all revascularization procedures for ischemic
diabetic foot patients at King’s College Hospital. Only patients who underwent pedal bypass
(dorsalis pedis artery plantar artery) were included as were patients who underwent pedal
arch angioplasty. Primary, primary assisted and secondary patency rates along with 30-day
mortality, major amputation rate, amputation-free survival, and overall survival at 1 year were
analyzed. Kaplan-Meier survival analysis, were used as appropriate. (Graphpad Prism 6.0)
Results: 51 patients underwent pedal bypasses or pedal arch angioplasty in the study
period. Median age was 72 years (range 46-90) and male to female ratio was 8:1. Comorbidities included diabetes mellitus (90%), hypertension (75%), end stage renal disease
(30%) and ischemic heart disease (30%). Primary, primary assisted and secondary patency
rates were 67%, 83% and 86% respectively. With no 30 day mortality, 1-year amputationfree survival was 85% and 1 year overall survival was 90%. Major amputation rate was 4%.
Conclusion: This study showed that pedal bypasses and pedal arch angioplasty have
excellent outcomes at 1 year. The two modalities complement each other and help prevent
amputations and save lives.
bypass to dorsalis pedis artery
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Page 7 of 11
P25.08
Role of spy angio in determining foot vascularity of diabetic patients -pre and post
stenting of tibial vessels.
Sandeep Raj Pandey, Medanta-The Medicity, Gurgaon, India
Purpose: To, evaluate the prognostic and diagnostic, role of, spy angio in, preventing diabtic
foot amputation in patients with tibial vessels disease.
Methods: A 56-year old female with a 20-year history of DM2, presented at our ER with,
painful ischemic, right foot . No ulcer or gangrene yet. Duplex revealed short segment tight
stenosis of the right mid ATA .We advised her to undergo PAG and futher proceed to
increase arterial flow to the her right foot .She underwent angioplasty and stenting of the left
ATA .Spy angio was used to determine the perfusion to the foot, as well as the efficacy of
the stenting in reintroducing blood flow .Previously patient had decreased vascularity to the
foot. Once stenting, was impeded, all digits filled in the foot .TCPO2 and ABI was done as
well pre and post op but didn’t give satisfactory results.
Results: Following the stenting, while the patient did experience markedly improved
waveform patterns and stent patency, the foot show increased vascularity. Finally, Spy
angio, determined adequate perfusion was available to the foot. Patient relieved of ischemic
pain.
Conclusion: With spy angiography, surface tissue viability can be determined. It is an
important prognostic, tool in preventing amputations from vascular deficiencies. It is superior
in comparisons to the transcutaneous partial pressure of oxygen test as well as other
noninvasive hemodynamic measurements.
pre op spy angio
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Page 8 of 11
P25.09
Bifurcated surgical bypass as bailout procedure in patients with critical limb
ischaemia (CLI) and diabetic foot ulcer (DFU)
Daniele Adami, University of Pisa, Pisa, Italy
Fabrizia Virgiliio, University of Pisa, Pisa, Italy
Alberto Piaggesi, University of Pisa, Pisa, Italy
Michele Marconi, University of Pisa, Pisa, Italy
Raffaella Berchiolli, University of Pisa, Pisa, Italy
Chiara Mattaliano, University of Pisa, Pisa, Italy
Mauro Ferrari, University of Pisa, Pisa, Italy
Aim: To test the safety and effectiveness of bifurcated surgical bypass to the tibial arteries at
the ankle level as a bailout intervention in CLI patients candidated to lower extremity
amputation (LEA) after previous failed revascularization procedures.
Methods: We retrospectively analysed the data of, 116 consecutive, patients with CLI
treated by open surgical approach Jan. 2011 - Apr. 2014. In 8 cases the indication of, LEA
after previous failed endovascular revascularizations (2.25/pts) was given. All patients had
DFU. Inclusion criteria for extreme lower limb revascularization were: no medical
contraindication for major surgery, presence of autologous vein conduit, patency of at least
one distal tibial artery directed to pedal vessels with another patent artery segment for
secondary bypass branch to improve runoff. Surgical planning was set after ultrasound
mapping (USM) and angiography. All patients were followed-up with USM at 1, 12 and, 24
months, respectively. Primary end point was, limb salvage rate, while secondary end points
were primary and secondary bypass patency rates.
Results: All patients (all type 2, aged 63.18±8.37 yrs, duration of diabetes 19.52±11.66 yrs;
HbA1c 8.2±1.4%) were treated under general anesthesia. Perioperative mortality and
morbidity rates were 0% and 37 8%, respectively; mean inhospital stay was 7.25±1.75 days.
The main distal target vessel was the dorsalis pedis in 5 cases, the posterior tibial, at the
ankle level in 2 patients and the plantar artery in 1 case. The secondary by-pass branch
landed on peroneal artery (6 cases), tibio-peroneal trunk (1 case) and infragenicular popliteal
artery (1 case), respectively. Minor amputations and surgical debridment were performed in
5 patients (62.2%), while no patient underwent to LEA. The 1-month primary patency rate
was 100%. At 12 months the primary patency rate was 87.5%(7/8) with limb salvage rate of
100%. At 24 months both, primary patency and limb salvage rates were 75%. Mortality rate
after 24 months was 25%.
Conclusions: In our experience the bifurcated bypass may improve the outflow with,
statisfactory limb salvage and mid-term patency rates. In these cases, accurate, preoperative USM and angiographic evaluations are essential to adequately plan the
intervention.
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Page 9 of 11
P25.10
To study the effects of short-term impinging of diabetic foot ulcers with vacuum
therapy on skin microcirculation to attain wound closure
Rumneek Sodhi, Medanta-The medicity, Haryana, India
Method: 19 diabetic foot ulcer patients with peripheral arterial disease (PAD) underwent
vacuum therapy on the P6 or P7 preset mode of the VACUUMED therapy system for 40
minutes each.The number of therapy sessions per week and the total number of sessions for
each patient was variable depending on the degree of PAD and the size and extent of the
wound. Number of session per week varied between 1 to 3 times per patient and the total
number of sessions ranged from about 3 to 10 sessions per patient.
The leg was positioned in an air-tight plexiglass cylinder in which hypobaric (-110 mm Hg)
and hyperbaric (70 mm Hg) pressure could be generated alternately, in order to improve
peripheral circulation and also supposedly reduce infection in the wound. All the wounds
were dressed daily with a non adhesive foam dressing.
The effect on skin microcirculation was investigated using parameters of transcutaneous
oxygen tension measurements (TcpO2) and serial photographs to observe wound healing at
each therapy visit.
Results: 3/19 patients experienced ischemic symptoms during VACUUMED therapy,
probably because the leg was pinched off through the inflation of the cuff. Patient’s capillary
microscopic parameters changed slightly at first vacuum. After several therapy sessions,
TcpO2 improved significantly in most patients (from 3 to 19 mmHg) with progressive wound
healing.
In Conclusion:VACUUMED therapy significantly improves skin perfusion and oxygenation
levels as evident with the increase in transcutaneous oxygen tension measurements
(TcpO2) which in turns stimulates wound healing.
We therefore conclude that this modality is a useful tool in the armamentarium of diabetic
foot care professionals aiming for wound closure
The study was not funded by anyone.
VACUUMED FLOW REGENERATION SYSTEM
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Page 10 of 11
P25.11
Vascular calcifications in diabetic patients affected by ischemic foot ulcers:
comparison between patients on dialysis and not
Marco Meloni, University of Tor Vergata, Rome, Italy
Valentina Izzo, University of Tor Vergata, Rome, RM, Italy
Erika Vainieri, University of Tor Vergata, Rome, Italy
Costantino Del Giudice, University of Tor Vergata, Rome, Italy
Valerio Da Ros, University of Tor Vergata, Rome, Italy
Laura Giurato, University of Tor Vergata, Rome, Italy
Valeria Ruotolo, University of Tor Vergata, Rome, Italy
Roberto Gandini, University of Tor Vergata, Rome, Italy
Luigi Uccioli, University of Tor Vergata, Rome, Italy
Aim: Dialysis is a strong risk factor for peripheral arterial disease (PAD) and vascular
calcification (VC). This condition increases the severity of vascular disease in diabetic
patients and the risk of both ulceration and amputation.(1 2) The aim of this study was to
evaluate the differences in terms of VC among patients on dialysis and not in a population of
diabetic subjects affected by critical limb ischemia (CLI) and foot ulcer (FU).
Methods: Among 456 diabetic patients who performed ET because of a condition of CLI
complicated by FU we have identified two groups in relation to dialysis therapy (D+)(n=60)
and not (D-)(n=396). We have selected patients with more severe PAD that needed at least
a new ET to reach limb salvage: n=18 (24.7%) from D+, n=61(14.7%) from D-. According to
peripheral arterial calcium system score (PACSS), we evaluated the severity and the
localization of VC in the vessels above the knee (ATK) and below the knee (BTK) (Tab.1).
Results: D+ required re-ET in a major number of occasion (24.7 vs 18%, p<0.043). In
relation to VC, D+ showed a more severe calcium disease (grade 4C PACSS) (56 5 vs 7
8%) (χ=0 001) and a higher rate of mixed calcifications BTK (59 vs 9 5%) (χ=0 0001) while
D- showed a higher involvement of intimal alone both ATK (57 9 vs 4 3%) (χ=0 0001) and
BTK (34 2 vs 9%) (χ=0 027).
Conclusions: Dialysis treatment increases dramatically the severity of PAD in diabetic
subjects.(3) Our data confirmed that ET failure is higher in D+ and they needed more
procedures to treat their condition. We retained that the VC could play a key role in the
worse outcomes of dialysed patients. In fact these results seem to be related to the severity
of VC in the vessels BTK, mainly to the simultaneous involvement both of intimal and medial
layers.
References
[1] Prompers L, Diabetologia 2008; 51(5): 747–755, [2] Gershater MA, Diabetologia 2009;
52(3): 398–407. [3] Lepantolo M, Diabetes Metab Res Rev 2012; 28(Suppl 1): 40-45
Table 1. Proposed Fluoroscopy/DSA based Peripheral Arterial Calcification Scoring System
(PACCS): intimal and medial vessel wall calcification at the target lesion site as assessed by high
intensity fluoroscopy and digital subtraction angiography (DSA) assessed in AP projection.
Grade 0: No visible calcium at the target lesion site
Grade 1: unilateral calcification < 5 cm; a) intimal calcification; b) medial calcification; c) mixed type
Grade 2: : unilateral calcification ≥ 5 cm; a) intimal calcification; b) medial calcification; c) mixed type
Grade 3: bilateral calcification < 5 cm; a) intimal calcification; b) medial calcification; c) mixed type
Grade 4: bilateral calcification ≥ 5 cm; a) intimal calcification; b) medial calcification; c) mixed type
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