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Subintimal Angioplasty: Our Experience In The Treatment Of 648 Chronic Total Occlusions

Eric C Scott, Andre Biuckians, Ryan E Light, Jessica R Burgess, Jean M Panneton, George H Meier, III.
Eastern Virginia Medical School, Norfolk, VA.

OBJECTIVES: The treatment of patients with disabling claudication (DC) or critical limb ischemia (CLI) secondary to chronic total occlusions has changed dramatically with the incorporation of subintimal angioplasty (SIA) into vascular surgery practice. To more clearly define technical feasibility, patency, and clinical outcomes of SIA, we reviewed our cumulative experience.

METHODS: A retrospective review of all patients who underwent SIA at our institution was performed. Patient history, demographics, procedural details, and follow-up information were collected and analyzed. Patency, limb salvage, and incidence of subsequent surgical bypass were determined by Kaplan-Meier analysis.

RESULTS: From December, 2002, through July, 2006, 648 independent SIA procedures were performed. The mean age of patients treated was 69±13 years. The femoropopliteal segment was treated in 71% of procedures; the remainder were performed for iliac, tibial artery, or multiple occlusions. Indications for intervention were CLI in 64% of patients and DC in 36%. Eighteen percent of patients were considered “non-operative” secondary to prohibitive operative risk or lack of surgical options. Technical success was achieved in 85% of procedures. Following successful SIA, the mean ankle-brachial index increased from 0.50±0.16 to 0.78±0.22 (P<.0001). Mean follow-up was 12.6 months (range, 0-46 months) and 30-day mortality was 1.2%. Primary patency at 1 and 3 years was 46% and 26%, respectively. Secondary patency was 73% and 50% at 1 and 3 years. Limb salvage in patients with critical limb ischemia was 83% and 72% at these intervals. Only 34% of patients who underwent successful SIA required surgical bypass in the following 3 years.

CONCLUSIONS: SIA is a technically feasible procedure for the revascularization of patients with lower extremity chronic total occlusions. The minimally invasive nature of the procedure allows treatment of many patients whom would otherwise be offered only primary amputation. Primary patency is lower than that of autologous vein bypass, but following additional percutaneous procedures, secondary patency is comparable to traditional surgical outcomes. Limb salvage and avoidance of surgical bypass are achieved in the majority of patients at 3 years following SIA.