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Duplex Derived Grey-Scale Median (GSM) Of Femoral/Popliteal Arterial Segments: A Novel Predictor Of Success Or Failure For Subintimal Dissections

Enrico Ascher, Natalie Marks, Alessandra Puggioni, Anil Hingorani.
Maimonides Medical Center, Brooklyn, NY.

OBJECTIVES: To assess whether GSM of the most distal portion of an occluded superficial femoral/popliteal (SFA/POP) arterial segment can predict successful lumen reentry and short term patency.

METHODS: Over the last 3 years, 108 patients (62% males) with a mean age of 73±10 years had 116 primary attempts at duplex-guided subintimal angioplasties of the SFA/POP. Critical ischemia was the indication in 42% of cases. Pre-procedural B-mode duplex images of the plaque at the most distal portion of the occluded segment were digitalized and normalized using Photoshop® software and standard criteria (grey level of 0 to 5 for luminal blood and 180 to 190 for the adventitia on a linear scale of 0 to 255). Overall, GSM of the plaque located within the most distal portion of the occluded arterial segment (1-2 centimeters) was recorded and analyzed in all cases. Several clinical parameters were also correlated with plaque GSM measurements.

RESULTS: Overall technical success rate of subintimal angioplasty procedures was 85%. The mean GSM for all cases was 22.9±13.5 (range 3 to 77). The mean GSM for the 99 successful cases was 18.4±7.8 and it was 48.8±10.5 for the 17 unsuccessful cases (p<0.0001). In 82 cases (71%) the GSM was ≤25 and reentry was possible in all these cases. Failure rates for GSM values over 25, 30 and 35 where 50%, 71% and 90%, respectively. The mean GSM in 64 diabetics (24±15) and 52 non-diabetics (21.5±11.4) was similar (p=0.34). The mean GSM in 52 patients with elevated serum creatinine (>1.5 mg/dL) was 23.5±15.1 and it was 22.4±12.2 for 64 patients with normal creatinine (p=0.65). In 7 cases of acute arterial thrombosis (30 days) the mean GSM was 20.9±8.6 and it was 18.2±7 for the remaining 92 cases that did not thrombose (p=0.39). At 6-month follow-up, the mean GSM of 47 patients with no evidence of restenosis by duplex was 17.8±7.8 while it was 18±6.8 for the 22 patients who developed severe restenosis (>70%) or reocclusion (p=0.4).

CONCLUSIONS: To our knowledge, this is the first report that attempts to identify predictors for successful reentry into the true lumen during subintimal SFA/POP angioplasties. We have shown that plaque echogenicity (duplex-derived GSM) can be used to predict successful reentry. Conversely, GSM is not a valid predictor of short-term patency for these reconstructions.