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ARTICLE |

Evaluation and Percutaneous Management of Atherosclerotic Peripheral Vascular Disease FREE

David M. Widlus, MD; Floyd A. Osterman, Jr, MD
[+] Author Affiliations

Reprint requests to Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, MD 21205-2191 (Dr Widlus).


JAMA. 1989;261(21):3148-3154. doi:10.1001/jama.1989.03420210096023
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Published online

ATHEROSCLEROTIC peripheral vascular disease (PVD) of the lower extremities deprives a person of the ability to exercise to their satisfaction, later of the ability to perform the activities of their daily life, and finally of their legs themselves. Peripheral vascular disease has long been managed by the vascular surgeon utilizing endarterectomy and peripheral arterial bypass.1-4 These surgical techniques have been shown to be effective in relieving symptoms and to be durable with the passage of time. Postoperative morbidity, rising health care costs, and refinement of percutaneous catheter technology have led to the development and use of nonsurgical modalities for the management of PVD.5 Patient acceptance of nonsurgical, percutaneous procedures such as percutaneous transluminal balloon angioplasty (PTA) is high.6 Increased utilization of these procedures has led to improved techniques and adjuncts to therapy, as well as more critical review of long-term results. This article will review the evaluation

REFERENCES

References 20-22,29,33-38,40-42,45-53.
References 21, 22, 24, 25, 29-32, 37, 41, 45, 46,48-51,55-57.
Inahara T, Scott CM.  Endarterectomy for segmental occlusive disease of superficial femoral artery . Arch Surg. 1981;;116:1547-1553.
Taylor LM Jr, Phinney ES, Porter JM.  Present status of revised vein bypass for lower extremity revascularization . J Vase Surg. 1986;;3:288-295.
Malone JM, Wesley WS, Goldstone J.  The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities . Arch Surg. 1975;;110:1300-1306.
Darling RC, Linton RR.  Durability of femoropopliteal reconstructions . Am J Surg. 1972;;123:472.
Doubilet P, Abrams HL.  The cost of underutilization, percutaneous transluminal angioplasty for peripheral vascular disease . N Engl J Med. 1984;;310:95-102.
White RI, Rizer DR, Shuman K, et al.  Streamlining operation of an admitting service for interventional radiology . Radiology. 1988;;168:127-130.
Strandness DE.  Evaluation of the patient for vascular surgery . Surg Clin North Am. 1974;;54:13.
Kaufman SL, Barth K, Kadir S, et al.  Hemodynamic measurements in the evaluation and follow up of transluminal angioplasty of the iliac and femoral arteries . Radiology. 1982;;142:329-336.
Neiman HL, Bergan JJ, Yad JST, Brandt TD, Greenberg M, O'Mart CS.  Hemodynamic assessment of PTA for lower extremity ischemia . Radiology. 1982;;143:639-643.
Baker JD, Dix D.  Variability of Doppler ankle pressures with arterial occlusive disease: an evaluation of ankle index and brachial-ankle pressure gradient . Surgery. 1981;;89:134-137.
Imparato AM, Kim GE, Crowley JG.  Intermittent claudication: its natural course . Surgery. 1975;;78:795.
Castaneda-Zuniga WR, Formanek A, Tadavarthy M, et al.  The mechanism of balloon angioplasty . Radiology. 1980;;135:565-571.
Saffitz JE, Totty WG, McClennan BL, Gilula LA.  Percutaneous transluminal angioplasty: radiological-pathological correlation . Radiology. 1980;; 141:651-654.
Morimoto S-I, Sekiguchi M, Endo M, et al.  Mechanism of luminal enlargement in PTCA and restenosis: a histopathological study of necropsied coronary arteries collected from various centers in Japan Jpn Circ J. , 1987;;51:1101-1115.
Dotter CT, Judkins MP.  Transluminal treatment of atherosclerotic obstruction: description of a new technique and preliminary report of its application . Circulation. 1964;;30:654-670.
Sos TA, Sniderman KW.  Percutaneous transluminal angioplasty . Semin Roentgenol. 1981;; 16:26-41.
Gruntzig A, Hopff H.  Perkutane Rekanalisation chronischer arterieller Verschlusse mit einem neuen Dilatations Katheter: Modifikation der Dottertechnik . Dtsch Med Wochenschr. 1974;;99:2502-2504.
Gruntzig A, Kumpe DA.  Technique of percutaneous transluminal angioplasty with the Gruntzig balloon catheter . AJR. 1979;;132:547-552.
Hewes RC, White RI Jr, Murray RR, et al.  Long-term results of superficial femoral artery angioplasty . AJR. 1986;;146:1025-1029.
Rubinstein AJ, Morag B, Peer A, Bass A, Schneiderman J.  Percutaneous transluminal recanalization of common iliac artery occlusions . Cardiovasc Intervent Radiol. 1987;;10:16-20.
Fletcher JP, Little JM, Fermanis GG, Simmons K.  Percutaneous transluminal angioplasty for severe lower extremity ischaemia . Aust N Z J Surg. 1986;;56:121-125.
Graziani L.  Percutaneous recanalization of total iliac and femoro-popliteal artery occlusions . Eur J Radiol. 1987;;7:91-93.
Korogi Y, Takahashi M.  Percutaneous transluminal angioplasty of totally occluded iliac arteries in high-risk patients . Br J Radiol. 1986;;59:1167-1170.
Murray RR Jr, Hewes RC, White RI Jr, et al.  Long-segment femoropopliteal stenoses: is angioplasty a boon or a bust? Radiology. 1987;;162:473-476.
Milford MA, Weaver FA, Lundell CJ, Yellin AE.  Femoropopliteal percutaneous transluminal angioplasty for limb salvage . J Vasc Surg. 1988;;8:292-299.
Martin EC, Fankuchen EI, Karlson KB, et al.  Angioplasty for femoral artery occlusion: comparison with surgery . AJR. 1981;;137:915-919.
Brown KT, Schoenberg NY, Moore ED, Sadderni S.  Percutaneous transluminal angioplasty of infrapopliteal vessels: preliminary results and technical considerations . Radiology. 1988;;169:75-78.
Zeitler E.  Drug treatment before and after percutaneous transluminal recanalization . In: Zeitler E, Gruntzig A, Schoop W, eds. Percutaneous Vascular Recanalization . Berlin, West Germany: Springer-Verlag; 1978;:73.
Gallino A, Mahler F, Probst P, Nachbur B.  Percutaneous transluminal angioplasty of arteries of the lower limbs: a 5 year follow-up . Circulation. 1984;;70:619-623.
Greenfield AJ.  Femoral, popliteal, and tibial arteries: percutaneous transluminal angioplasty . AJR. 1980;;135:927-935.
Tonnesen KH, Sager P, Karle A, Henriksen L, Jorgensen B.  Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery . Cardiovasc Intervent Radiol. 1988;;11:127-131.
Krepel VM, van Andel GP, van Erp WFM, Breslau PJ.  Percutaneous transluminal angioplasty of the femoropopliteal artery: initial and long-term results . Radiology. 1985;;156:325-328.
Waltman AC.  Percutaneous transluminal angioplasty: iliac and deep femoral arteries . AJR. 1980;;135:921-925.
Colapinto RF, Stronell RD, Johnston WK.  Transluminal angioplasty of complete iliac obstructions . AJR. 1986;;146:859-862.
Mortarjeme A, Keifer JW, Zuska AJ.  Percutaneous transluminal angioplasty of the iliac arteries: 66 experiences . AJR. 1980;;135:937-944.
Zeitler E, Richter EI, Roth FJ, Schoop W.  Results of percutaneous transluminal angioplasty . Radiology. 1983;;146:57-60.
Schneider E, Gruntzig A, Bollinger A.  Langzeitergebnisse nach perkutaner transluminaler Angioplastie (PTA) bei 882 konsekutiven Patienten mit iliakalen und femoro-poplitealen Obstruktionen . Vasa. 1982;;11:322-326.
Kadir S, White RI Jr, Kaufman SL, et al.  Longterm results of iliac angioplasty . Surgery. 1983;; 94:10-14.
Schwarten DE, Cutcliff WB.  Arterial occlusive disease below the knee: treatment with percutaneous transluminal angioplasty performed with lowprofile catheters and steerable guide wires . Radiology . 1988;;169:71-74.
van Andel GJ, Van Erp WFM, Krepel VM, Breslau PJ.  Percutaneous transluminal dilatation of the iliac artery: long-term results . Radiology. 1985;;156:321-323.
Johnston W, Rae M, Jogg-Johnston SA, et al.  Five-year results of a prospective study of percutaneous transluminal angioplasty . Ann Surg. 1987;; 206:403-413.
Morag B, Rubeinstein Z, Kessler A, Schneiderman J, Levinkopf M, Bass A.  Percutaneous transluminal angioplasty of the distal abdominal aorta and its bifurcation . Cardiovasc Intervent Radiol. 1987;;10:129-133.
Charlebois N, Saint-Georges G, Hudon G.  Percutaneous transluminal angioplasty of the lower abdominal aorta . AJR. 1986;;146:369-371.
Tegtmeyer CJ, Kellum CD, Kron IL, Mentzer RM Jr.  Percutaneous transluminal angioplasty in the region of the aortic bifurcation—the two-balloon technique with results and long-term follow-up study . Radiology. 1985;;157:661-665.
Sampson RH, Sprayregen S, Veith FJ, Scher LA, Gupta SK, Ascer E.  Management of angioplasty complications, unsuccessful procedures and early and late failures . Ann Surg. 1984;;199:234-239.
Wilms G, Nevelsteen A, Baert A, Suy R.  Aorta/peripheral arteries—intraoperative angioplasty . Cardiovasc Intervent Radiol. 1987;;10:8-12.
Knight RW, Kenney GJ, Lewis EE, Johnston GG.  Percutaneous transluminal angioplasty: results and surgical implications . Am J Surg. 1984;;147:578-582.
Spence RK, Freiman DB, Gatenby R, et al.  Long-term results of transluminal angioplasty of the iliac and femoral arteries . Arch Surg. 1981;;116:1377-1386.
Zeitler E.  Percutaneous dilatation and recanalization of iliac and femoral arteries . Cardiovasc Intervent Radiol. 1980;;3:207-212.
Olbert F, Kasprzak P, Muzika N, Schlegl A.  Perkutane transluminale Dilatation und Rekanalisation: Langzeitergebnisse und Erfahrungsbericht mit einem neuen Kathetersystem . Vasa. 1982;; 11:327-331.
Borozan PG, Schuler JJ, Spigos DG, Flanigan DP.  Long-term hemodynamic evaluation of lower extremity percutaneous transluminal angioplasty . J Vase Surg. 1983;;2:785-793.
Daniell SJN, Dacie JE, Lumley JSP.  Is percutaneous transluminal angioplasty for common iliac occlusion a safe procedure? J Intervent Radiol. 1987;;2:89-95.
Colapinto RF, Harries-Jones EP, Johnston KW.  Percutaneous transluminal angioplasty of peripheral vascular disease: a two-year experience . Cardiovasc Intervent Radiol. 1980;;3:213-218.
Auster M, Kadir S, Mitchell SE, et al.  Iliac artery occlusion: management with intrathrombus streptokinase infusion and angioplasty . Radiology. 1984;;153:385-388.
Probst P, Cerny P, Owens A, Mahler F.  Patency after femoral angioplasty correlation of angiographic appearance with clinical findings . AJR. 1983;;140:1227-1232.
van Andel GJ.  Long-term results of iliac and femoral angioplasty . Ann Radiol. 1981;;24:365-368.
Waltman AC, Greenfield AJ, Novelline RA, et al.  Transluminal angioplasty of the iliac and femoropopliteal arteries . Arch Surg. 1982;;117:1218-1222.
Starck EE, McDermott J, Crummy AB, Heydwold AV.  Angioplasty of the popliteal and tibial arteries . Semin Intervent Radiol. 1984;;1:269-277.
Sprayregen S, Sniderman KW, Sos TA, Vieux U, Singer A, Veith FJ.  Popliteal artery branches: percutaneous transluminal angioplasty . AJR. 1980;;135:945-950.
Joly S, Bonan R, Palisaitis D, et al.  Treatment of recurrent restenosis with repeat percutaneous transluminal coronary angioplasty . Am J Cardiol. 1988;;61:906-908.
Barnes RW.  Initial results after percutaneous transluminal angioplasty in femoral and iliac obstruction . Vasa. 1982;;11:301-304.
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Maynar M, Reyes R, Cabrera V, et al.  Percutaneous atherectomy with Simpson atherectomy device in the management of arterial stenosis . Semin Intervent Radiol. 1988;;5:247-252.
Maynar M, Reyes R, Cabrera V, et al.  Percutaneous atherectomy of iliac arteries . Semin Intervent Radiol. 1988;;5:253-255.
Newman GE, Miner DG, Sussman SK, Phillips HR, Mikat EM, McCann RL.  Peripheral artery artherectomy: description of technique and report of initial results . Radiology. 1988;;169:677-680.
Dotter CT.  Transluminally-placed coilspring endarterial tube grafts: long-term patency in canine popliteal artery . Invest Radiol. 1969;;4:329-332.
Palmaz JC.  Balloon-expandable intravascular stent . AJR. 1988;;150:1263-1269.
Zollikofer CL, Largiader I, Bruhlmann WF, Uhlschmid GK, Marty AH.  Endovascular stenting of veins and grafts: preliminary clinical experience . Intervent Radiol. 1988;;167:707-712.
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Puel J, Juilliere Y, Bertrand ME, Rickards AF, Sigwart U, Serruys PW.  Early and late assessment of stenosis geometry after coronary arterial stenting . Am J Cardiol. 1988;;61:546-553.
Uchida BT, Putnam JS, Rosch J.  Modifications of Gianturco expandable wire stents . AJR. 1988;;150:1185-1187.

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References 20-22,29,33-38,40-42,45-53.
References 21, 22, 24, 25, 29-32, 37, 41, 45, 46,48-51,55-57.
Inahara T, Scott CM.  Endarterectomy for segmental occlusive disease of superficial femoral artery . Arch Surg. 1981;;116:1547-1553.
Taylor LM Jr, Phinney ES, Porter JM.  Present status of revised vein bypass for lower extremity revascularization . J Vase Surg. 1986;;3:288-295.
Malone JM, Wesley WS, Goldstone J.  The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities . Arch Surg. 1975;;110:1300-1306.
Darling RC, Linton RR.  Durability of femoropopliteal reconstructions . Am J Surg. 1972;;123:472.
Doubilet P, Abrams HL.  The cost of underutilization, percutaneous transluminal angioplasty for peripheral vascular disease . N Engl J Med. 1984;;310:95-102.
White RI, Rizer DR, Shuman K, et al.  Streamlining operation of an admitting service for interventional radiology . Radiology. 1988;;168:127-130.
Strandness DE.  Evaluation of the patient for vascular surgery . Surg Clin North Am. 1974;;54:13.
Kaufman SL, Barth K, Kadir S, et al.  Hemodynamic measurements in the evaluation and follow up of transluminal angioplasty of the iliac and femoral arteries . Radiology. 1982;;142:329-336.
Neiman HL, Bergan JJ, Yad JST, Brandt TD, Greenberg M, O'Mart CS.  Hemodynamic assessment of PTA for lower extremity ischemia . Radiology. 1982;;143:639-643.
Baker JD, Dix D.  Variability of Doppler ankle pressures with arterial occlusive disease: an evaluation of ankle index and brachial-ankle pressure gradient . Surgery. 1981;;89:134-137.
Imparato AM, Kim GE, Crowley JG.  Intermittent claudication: its natural course . Surgery. 1975;;78:795.
Castaneda-Zuniga WR, Formanek A, Tadavarthy M, et al.  The mechanism of balloon angioplasty . Radiology. 1980;;135:565-571.
Saffitz JE, Totty WG, McClennan BL, Gilula LA.  Percutaneous transluminal angioplasty: radiological-pathological correlation . Radiology. 1980;; 141:651-654.
Morimoto S-I, Sekiguchi M, Endo M, et al.  Mechanism of luminal enlargement in PTCA and restenosis: a histopathological study of necropsied coronary arteries collected from various centers in Japan Jpn Circ J. , 1987;;51:1101-1115.
Dotter CT, Judkins MP.  Transluminal treatment of atherosclerotic obstruction: description of a new technique and preliminary report of its application . Circulation. 1964;;30:654-670.
Sos TA, Sniderman KW.  Percutaneous transluminal angioplasty . Semin Roentgenol. 1981;; 16:26-41.
Gruntzig A, Hopff H.  Perkutane Rekanalisation chronischer arterieller Verschlusse mit einem neuen Dilatations Katheter: Modifikation der Dottertechnik . Dtsch Med Wochenschr. 1974;;99:2502-2504.
Gruntzig A, Kumpe DA.  Technique of percutaneous transluminal angioplasty with the Gruntzig balloon catheter . AJR. 1979;;132:547-552.
Hewes RC, White RI Jr, Murray RR, et al.  Long-term results of superficial femoral artery angioplasty . AJR. 1986;;146:1025-1029.
Rubinstein AJ, Morag B, Peer A, Bass A, Schneiderman J.  Percutaneous transluminal recanalization of common iliac artery occlusions . Cardiovasc Intervent Radiol. 1987;;10:16-20.
Fletcher JP, Little JM, Fermanis GG, Simmons K.  Percutaneous transluminal angioplasty for severe lower extremity ischaemia . Aust N Z J Surg. 1986;;56:121-125.
Graziani L.  Percutaneous recanalization of total iliac and femoro-popliteal artery occlusions . Eur J Radiol. 1987;;7:91-93.
Korogi Y, Takahashi M.  Percutaneous transluminal angioplasty of totally occluded iliac arteries in high-risk patients . Br J Radiol. 1986;;59:1167-1170.
Murray RR Jr, Hewes RC, White RI Jr, et al.  Long-segment femoropopliteal stenoses: is angioplasty a boon or a bust? Radiology. 1987;;162:473-476.
Milford MA, Weaver FA, Lundell CJ, Yellin AE.  Femoropopliteal percutaneous transluminal angioplasty for limb salvage . J Vasc Surg. 1988;;8:292-299.
Martin EC, Fankuchen EI, Karlson KB, et al.  Angioplasty for femoral artery occlusion: comparison with surgery . AJR. 1981;;137:915-919.
Brown KT, Schoenberg NY, Moore ED, Sadderni S.  Percutaneous transluminal angioplasty of infrapopliteal vessels: preliminary results and technical considerations . Radiology. 1988;;169:75-78.
Zeitler E.  Drug treatment before and after percutaneous transluminal recanalization . In: Zeitler E, Gruntzig A, Schoop W, eds. Percutaneous Vascular Recanalization . Berlin, West Germany: Springer-Verlag; 1978;:73.
Gallino A, Mahler F, Probst P, Nachbur B.  Percutaneous transluminal angioplasty of arteries of the lower limbs: a 5 year follow-up . Circulation. 1984;;70:619-623.
Greenfield AJ.  Femoral, popliteal, and tibial arteries: percutaneous transluminal angioplasty . AJR. 1980;;135:927-935.
Tonnesen KH, Sager P, Karle A, Henriksen L, Jorgensen B.  Percutaneous transluminal angioplasty of the superficial femoral artery by retrograde catheterization via the popliteal artery . Cardiovasc Intervent Radiol. 1988;;11:127-131.
Krepel VM, van Andel GP, van Erp WFM, Breslau PJ.  Percutaneous transluminal angioplasty of the femoropopliteal artery: initial and long-term results . Radiology. 1985;;156:325-328.
Waltman AC.  Percutaneous transluminal angioplasty: iliac and deep femoral arteries . AJR. 1980;;135:921-925.
Colapinto RF, Stronell RD, Johnston WK.  Transluminal angioplasty of complete iliac obstructions . AJR. 1986;;146:859-862.
Mortarjeme A, Keifer JW, Zuska AJ.  Percutaneous transluminal angioplasty of the iliac arteries: 66 experiences . AJR. 1980;;135:937-944.
Zeitler E, Richter EI, Roth FJ, Schoop W.  Results of percutaneous transluminal angioplasty . Radiology. 1983;;146:57-60.
Schneider E, Gruntzig A, Bollinger A.  Langzeitergebnisse nach perkutaner transluminaler Angioplastie (PTA) bei 882 konsekutiven Patienten mit iliakalen und femoro-poplitealen Obstruktionen . Vasa. 1982;;11:322-326.
Kadir S, White RI Jr, Kaufman SL, et al.  Longterm results of iliac angioplasty . Surgery. 1983;; 94:10-14.
Schwarten DE, Cutcliff WB.  Arterial occlusive disease below the knee: treatment with percutaneous transluminal angioplasty performed with lowprofile catheters and steerable guide wires . Radiology . 1988;;169:71-74.
van Andel GJ, Van Erp WFM, Krepel VM, Breslau PJ.  Percutaneous transluminal dilatation of the iliac artery: long-term results . Radiology. 1985;;156:321-323.
Johnston W, Rae M, Jogg-Johnston SA, et al.  Five-year results of a prospective study of percutaneous transluminal angioplasty . Ann Surg. 1987;; 206:403-413.
Morag B, Rubeinstein Z, Kessler A, Schneiderman J, Levinkopf M, Bass A.  Percutaneous transluminal angioplasty of the distal abdominal aorta and its bifurcation . Cardiovasc Intervent Radiol. 1987;;10:129-133.
Charlebois N, Saint-Georges G, Hudon G.  Percutaneous transluminal angioplasty of the lower abdominal aorta . AJR. 1986;;146:369-371.
Tegtmeyer CJ, Kellum CD, Kron IL, Mentzer RM Jr.  Percutaneous transluminal angioplasty in the region of the aortic bifurcation—the two-balloon technique with results and long-term follow-up study . Radiology. 1985;;157:661-665.
Sampson RH, Sprayregen S, Veith FJ, Scher LA, Gupta SK, Ascer E.  Management of angioplasty complications, unsuccessful procedures and early and late failures . Ann Surg. 1984;;199:234-239.
Wilms G, Nevelsteen A, Baert A, Suy R.  Aorta/peripheral arteries—intraoperative angioplasty . Cardiovasc Intervent Radiol. 1987;;10:8-12.
Knight RW, Kenney GJ, Lewis EE, Johnston GG.  Percutaneous transluminal angioplasty: results and surgical implications . Am J Surg. 1984;;147:578-582.
Spence RK, Freiman DB, Gatenby R, et al.  Long-term results of transluminal angioplasty of the iliac and femoral arteries . Arch Surg. 1981;;116:1377-1386.
Zeitler E.  Percutaneous dilatation and recanalization of iliac and femoral arteries . Cardiovasc Intervent Radiol. 1980;;3:207-212.
Olbert F, Kasprzak P, Muzika N, Schlegl A.  Perkutane transluminale Dilatation und Rekanalisation: Langzeitergebnisse und Erfahrungsbericht mit einem neuen Kathetersystem . Vasa. 1982;; 11:327-331.
Borozan PG, Schuler JJ, Spigos DG, Flanigan DP.  Long-term hemodynamic evaluation of lower extremity percutaneous transluminal angioplasty . J Vase Surg. 1983;;2:785-793.
Daniell SJN, Dacie JE, Lumley JSP.  Is percutaneous transluminal angioplasty for common iliac occlusion a safe procedure? J Intervent Radiol. 1987;;2:89-95.
Colapinto RF, Harries-Jones EP, Johnston KW.  Percutaneous transluminal angioplasty of peripheral vascular disease: a two-year experience . Cardiovasc Intervent Radiol. 1980;;3:213-218.
Auster M, Kadir S, Mitchell SE, et al.  Iliac artery occlusion: management with intrathrombus streptokinase infusion and angioplasty . Radiology. 1984;;153:385-388.
Probst P, Cerny P, Owens A, Mahler F.  Patency after femoral angioplasty correlation of angiographic appearance with clinical findings . AJR. 1983;;140:1227-1232.
van Andel GJ.  Long-term results of iliac and femoral angioplasty . Ann Radiol. 1981;;24:365-368.
Waltman AC, Greenfield AJ, Novelline RA, et al.  Transluminal angioplasty of the iliac and femoropopliteal arteries . Arch Surg. 1982;;117:1218-1222.
Starck EE, McDermott J, Crummy AB, Heydwold AV.  Angioplasty of the popliteal and tibial arteries . Semin Intervent Radiol. 1984;;1:269-277.
Sprayregen S, Sniderman KW, Sos TA, Vieux U, Singer A, Veith FJ.  Popliteal artery branches: percutaneous transluminal angioplasty . AJR. 1980;;135:945-950.
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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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