Basic anatomy of the lower limbs


The large caliber abdominal aorta (1) terminates by forking (bifurcation) into two large common iliac arteries (2) that have practically no side branches.

Each of these arteries also bifurcates into branches: The internal iliac artery (3), also called the hypogastric artery, that supplies all the organs of the pelvis and the genitalia with blood, and the external iliac artery (4).

The common femoral artery (5) is a continuation of the external iliac artery. It lies at the root of the thigh and is the most frequently used artery for arterial approach in all diagnostic and interventional procedures.

The common femoral artery rapidly divides into the superficial femoral artery (6), which runs on the interior part of the thigh and has few if any sidebranches, and the profound femoral artery (7) which is responsible for supplying blood to all muscles of the thigh.

The superficial femoral artery is continued by the popliteal artery (8), which passes to the calf behind the knee joint.

In the superior (upper) part of the calf, the popliteal artery divides into three branches (two tibial arteries (9) and one interosseous artery), which are responsible for supplying blood to all the muscles of the calf.

All three of them descend to the leg where they form an anastomotic plexus that supplies blood to all local tissue.

PVD is a common circulation problem in which arteries that carry blood to the arms or legs become narrow or clogged and the blood flow gets slower or stops.

Diminished blood flow to a part of the body may cause discomfort because the blood carries essential substances such as oxygen and nutrients to all the cells.

If the blood flow to a certain part of a limb stops completely for a few hours, that part may suffer up to irreversible damage.

This phenomenon is called gangrene and the only available treatment is amputation.

How common is PVD?


Every year millions of people are affected by this disease, which is characterized by an insufficient supply of blood to a certain limb, or part of a limb, because of significant atherosclerotic narrowing located in the arteries.

The disease most often affects the inferior (lower) limbs, but can sometimes occur in the arms where its progression is generally milder. Many people live with the symptoms of PVD believing, that is a normal part of the aging process.

The pain, which is the main symptom, is often attributed to arthritis (a disease of the joints and bones more frequently encountered in older age). The condition can often be successfully treated by an interventional radiologist or by an interventional cardiologist, who is fully trained in peripheral vascular interventions.Sometimes the intima that covers the plaque can rupture unexpectedly and expose plaque content to the circulating blood.This leads to platelet aggregation and blood coagulation, which obstructs blood flow by forming a thrombus (blood clot).When the plaque obstructs more than 70-80% of the vessel’s diameter, symptoms can occur due to restricted blood flow. The plaque can continue to grow until the vessel is totally blocked.

When the plaque ruptures suddenly, the vessel quickly becomes totally blocked with a blood clot. If the blockage is not removed immediately, that part of the limb, usually a limb extremity (for example, a finger or a toe), part of a leg or the entire leg may become irreversibly damaged and die. The mechanisms briefly described above will help you understand the way in which the symptoms of this disease can occur.

The disease can remain asymptomatic for a very long time (often for the first four decades of life).When the disease is fairly well advanced, you may experience symptoms produced by lack of adequate blood and oxygen supply to a certain organ.The usual treatment alternative is surgery, and amputation of the leg or fingers may be necessary.

The main symptom is pain in the limbs. This mostly occurs during physical exertion when the body’s requirement of oxygenated blood is increased. In time, the pain may be progressive and occur at lower levels of physical activity. Eventually, it may appear at rest and become almost continuous. If blood flow to a certain tissue is chronically or totally obstructed, that tissue may die.

If, for example, blood flow to a foot or toe is totally blocked, the tissue of that foot or toe dies (necrosis) and becomes affected with gangrene. Atherosclerotic disease can not only induce arterial narrowings it can also take the form of weakening and thinning the artery wall, in which a bulge develops – much the same way as in a weak tire wall.

The localized bulge is called an aneurysm that can progressively enlarge up to spontaneously rupture resulting in a hemorrhage.This can cause death if a large artery like the aorta is involved. The risk of such an aneurysm rupturing is proportional to its diameter. The greater its diameter, the higher the risk of rupture and severe hemorrhage. The aneurysms can also lead to thrombosis or embolism in the distal smaller arteries.

When the thrombus forms, small parts of it may rupture and migrate via the blood flow. The small parts that rupture are called emboli and the process is called an embolism.

Such an embolus may suddenly block a smaller distal artery producing the same consequences as locally activated blood clotting: ischemic gangrene.

The reduction in peripheral blood flow can also be due to an accident or injury, but it is more often the result of atherosclerotic disease. Smoking is one of the most frequent causes of gangrene of the lower limbs, but fortunately this cause can be rather easily “treated” by quitting


How can PVD be treated

  • Lifestyle changes
  • Medication
  • Interventional radiology treatment
  • Surgery

What is the best treatment?

The best treatment depends on a number of factors, including the overall condition of your health and the seriousness of your disease. Sometimes, a lifestyle change is sufficient to stop the progress of PVD. In other cases, medication and procedures to open clogged vessels are necessary.

Interventional Radiology

Background and history

  • The first therapeutical application of cardiovascular catheterization was invented by Charles Dotter and Melvin Judkins in 1964.
  • They developed an intravascular catheter system that could be advanced inside a peripheral artery to the site of an atherosclerotic narrowing, in order to relieve it by dilatation.
  • The procedure developed rapidly at the beginning of the 80s and as more and more physicians were trained to apply it, a lot of experience in using it was gained.
  • Today peripheral intervention techniques are the most widely used procedures in treating peripheral atherosclerotic artery disease by a non surgical method.
  • Interventional radiologists are specially trained doctors who use x-ray and other imaging techniques to “see” inside the body and diagnose Peripheral Vascular Disease (PVD). They use special methods of treatment that may avoid surgical interventions.
  • These methods of treatment are minimally invasive and gain access to major vessels by puncturing peripheral arteries and/or veins.
  • They guide long narrow tubes (catheters) through the blood vessels to access the diseased part of the vessel involved.

Some advantages of interventional radiology

  • Low operating risk in patients with associated severe vascular or systemic disease such as severe brain and/or coronary atherosclerosis.
  • Less traumatic than surgical intervention (involving small incisions no larger than the lead tip of a pencil).
  • Low operating risk in patients with associated severe vascular or systemic disease such as severe brain and/or coronary atherosclerosis.
  • Lower mortality and morbidity.
  • Peripheral Transluminal Angioplasty (PTA) with or without stenting, has been clearly demonstrated to reduce the rate of amputation in 86% of patients that have suitable lesions for interventional treatment.
  • General anaesthesia is usually not required; the procedures are performed with local anaesthesia given by injection at the site of the vascular access.
  • Less painful, as lesions are much smaller.
  • Shorter hospital stay.
  • Less expensive than surgical procedures depending on the type of materials used to treat a particular illness.

What is the difference between:

Peripheral Intervention
An interventional radiologist uses x-rays and other imaging devices to guide thin catheters and other small tools through the peripheral arteries to treat an illness without having to open up an area over the diseased part of the artery.
Conventional vasular surgery

Conventional vascular surgery
A traditional surgeon makes an incision (a cut) to open up an area of the body. He or she looks directly at the diseased segment or organ and repairs it.

Peripheral Stents


Intravascular peripheral stents were developed to adress the limitations of balloon angioplasty including acute complications and unsatisfactory results that occurred in peripheral interventions.

What is a peripheral stent?

A peripheral stent is a small vascular prosthesis (tube) consisting of stainless steel, nitinol or titanium wires.

These wires are specifically designed so that the stent can be mounted on deflated balloon catheters. Positioning the deflated balloon with the unexpanded stent mounted on it inside a diseased vessel and inflating the balloon at high pressure deploys the stent against the vessel wall.
The stent remains in the vessel acting as a scaffold to keep the vessel open.

Stents are classified according to their design, basic material they are made of, or the method of deployment. The type of stent used, (diameter, length, and manufacture) should be left to the operating doctor to decide, as he/she is the only one that can best judge all the parameters.

When are peripheral stents used?

If a vessel does not respond properly to balloon inflations and remains narrowed or does not open enough, it might be necessary to implant a stent. Stents were developed to reduce immediate recoil of the vessel narrowing and to improve immediate and long-term results of Percutaneous Transluminal Angioplasty (PTA) mainly in anatomically unfavorable narrowings.

Peripheral stent placement

A peripheral stent can be implanted in the peripheral artery at the time of PTA. It acts as a scaffolding device, which remains in the treated artery to ensure the passage of blood for a longer period.

Belgian Society Of Cardiology
Cyprus Society of Cardiology
Czech Society Of Cardiology
European Society of Cardiology
German Cardiac Society
German Society of Vascular Surgery
Hellenic Society of Cardiology
Iranian Society Of Interventional Cardiology
Japanese Educational Clinical Cardiology Society
Jordan Society of Cardiology
Lebanese Society of Cardiology and Cardiac Surgery
Pakistan Society of Cardiology
Brazilian Society Of Cardiology
Brazilian Society Of Interventional Cardiology
Society for Cardiovascular Angiography & Interventions
Singapore Society of Cardiology
Spanish Association of Nursing in Cardiology