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Therapeutic X-ray endovascular interventions 1) coronary angioplasty and stenting of coronary arteries 2) angioplasty of arteries of the lower extremities 3) implantation of a CAV filter in patients with a risk of pulmonary embolism (floating thrombi) or with recurrent pulmonary embolism 4) treatment of brain diseases (aneurysms, arteriovenous fistulas, carotid-cavernous anastomoses)

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endovascular intervention AND systematic review

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2024 2025 guidelines coronary intervention peripheral artery disease IVC filter neurointerventional aneurysm endovascular

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https://www.acc.org/latest-in-cardiology/articles/2025/04/01…

Therapeutic X-ray endovascular interventions

These are minimally invasive image-guided procedures performed through arterial or venous catheters. Fluoroscopy and digital-subtraction angiography guide wires, balloons, stents, coils, filters, or embolic material to the target vessel. They are usually performed via radial, femoral, or occasionally venous access, using iodinated contrast.

1. Coronary angioplasty and stenting

Purpose: Restore myocardial blood flow in coronary artery stenosis or occlusion, especially in acute coronary syndrome or symptomatic coronary artery disease.
Method
  1. A catheter is introduced through the radial or femoral artery and advanced to the coronary ostium.
  2. Coronary angiography identifies the stenosis.
  3. A guidewire crosses the lesion.
  4. A balloon is inflated to dilate the narrowed segment, called percutaneous transluminal coronary angioplasty.
  5. In most cases, a stent, commonly a drug-eluting stent, is deployed to scaffold the vessel and reduce restenosis.
A stent is an expandable mesh tube that maintains lumen patency after balloon dilatation. Guyton and Hall Textbook of Medical Physiology, p. 275. The current ACS guidance supports radial access to reduce bleeding and vascular complications, intravascular imaging guidance for PCI, and complete revascularization in appropriately selected ACS patients, summarized by the ACC/AHA guidance update.
Major complications: access-site bleeding, arterial dissection or perforation, acute thrombosis, distal embolization, myocardial infarction, contrast-associated kidney injury, and later in-stent restenosis or stent thrombosis. Antiplatelet treatment after stenting is central to prevention of thrombosis.

2. Angioplasty of lower-extremity arteries

Purpose: Treat peripheral arterial disease affecting the iliac, femoropopliteal, or infrapopliteal arteries.
Indications
  • Lifestyle-limiting claudication despite exercise therapy and best medical treatment
  • Chronic limb-threatening ischemia, including rest pain, ischemic ulcers, or gangrene
  • Acute limb ischemia in selected circumstances, often in combination with thrombolysis or thrombectomy
Method
  • Angiography maps the stenosis or occlusion.
  • A guidewire crosses the lesion.
  • Balloon angioplasty dilates the artery.
  • Depending on anatomy and the result, the interventionist may use drug-coated balloons, atherectomy, thrombectomy, stents, or covered stent grafts.
For stable claudication, revascularization is primarily intended to improve function and quality of life, not routinely to prevent limb loss. It is generally considered after structured exercise and pharmacotherapy have not relieved major symptoms. Goldman-Cecil Medicine, p. 767. The 2024 ESC peripheral arterial guidance addresses assessment and treatment across peripheral arterial and aortic disease.
Major complications: puncture-site hematoma, embolization, thrombosis, arterial dissection, acute vessel closure, restenosis, contrast reaction, and renal injury.

3. Inferior vena cava filter implantation

The correct term is IVC filter, not “CAV filter.”
Purpose: Prevent a large thrombus from the deep veins of the legs or pelvis from reaching the pulmonary arteries and causing pulmonary embolism. The filter is usually deployed in the infrarenal inferior vena cava through femoral or internal jugular venous access.
Appropriate situations
  • Acute venous thromboembolism with an absolute contraindication to therapeutic anticoagulation, such as active major bleeding
  • Recurrent pulmonary embolism or propagation of venous thrombus despite adequate anticoagulation in selected patients
  • Occasionally, a high-risk mobile or “floating” iliofemoral/IVC thrombus when anticoagulation cannot be used or fails, after individualized specialist assessment
An IVC filter is not a substitute for anticoagulation when anticoagulation is safe and effective. The preferred strategy is usually a retrievable filter, followed by prompt removal when the temporary indication has resolved. Filters can trap large emboli and may be removed after the high-risk period. Gray’s Anatomy for Students, p. 454. Textbook guidance emphasizes filters for contraindication to anticoagulation or PE despite adequate therapy, rather than routine prophylactic use. Sabiston Textbook of Surgery, Vascular Disease section.
Complications: filter thrombosis, increased DVT risk, migration, tilt, IVC penetration, fracture, failure to retrieve, and recurrent PE despite the filter.

4. Endovascular treatment of intracranial vascular disease

Intracranial aneurysms

Goal: Exclude the aneurysm from the circulation while preserving flow in normal parent vessels, thereby preventing rupture or rebleeding.
Techniques
  • Detachable platinum coil embolization
  • Balloon-assisted coiling for wide-neck aneurysms
  • Stent-assisted coiling
  • Flow-diverting stents for selected large, wide-neck, or complex aneurysms
  • Intrasaccular flow-disruption devices in selected anatomy
In coiling, soft platinum coils are placed inside the aneurysm through a microcatheter, promoting thrombosis and isolating it from circulation. Miller’s Anesthesia, Endovascular Treatment of Cerebral Aneurysms. Choice between coiling, flow diversion, and microsurgical clipping depends on rupture status, location, neck width, morphology, branch involvement, age, comorbidity, and local expertise.

Brain arteriovenous malformations and arteriovenous fistulas

Goal: Occlude the abnormal high-flow artery-to-vein connection, reduce hemorrhage risk, treat venous hypertension, or facilitate surgery/radiosurgery.
Technique: A microcatheter is advanced into feeding arteries and liquid embolic agents, such as n-butyl cyanoacrylate or ethylene-vinyl alcohol copolymer, or coils are delivered. Endovascular embolization may be curative for a small fistula, but for many AVMs it is one component of multidisciplinary treatment with microsurgery and/or stereotactic radiosurgery.

Carotid-cavernous fistula

This is an abnormal communication between the carotid arterial system and the cavernous sinus. Symptoms may include red eye, proptosis, pulsatile tinnitus, diplopia, raised intraocular pressure, and visual loss.
Treatment: Transarterial or transvenous embolization with coils and, in selected cases, liquid embolic material or covered stenting. The aim is closure of the fistula while maintaining normal carotid circulation when possible.
Digital-subtraction angiography remains particularly important for endovascular treatment and for detecting small dural or pial AV fistulas that may not be evident on noninvasive imaging. Grainger & Allison’s Diagnostic Radiology, p. 1370.
Neurologic procedure risks: ischemic stroke, intracranial hemorrhage, vessel perforation or dissection, thromboembolism, cranial nerve palsy, aneurysm recurrence or recanalization, contrast complications, and radiation exposure.

Core principle

The benefit of every endovascular intervention must exceed its procedural and long-term risk. Selection is based on symptoms, vascular anatomy, severity of disease, likelihood of technical success, alternative medical or surgical options, bleeding risk, renal function, and the availability of an experienced multidisciplinary team.
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