Subintimal Angioplasty May Aid In Lower Limb Salvage

By Giancarlo La Giorgia

< previous article | Table of Contents | next article >

TORONTO -- Subintimal angioplasty is "clearly the way forward" for treating claudication and critical limb ischemia, said the technique's creator, Dr. Amman Bolia, at the annual meeting of the Society of Interventional Radiology.

Clinical studies on subintimal angioplasty (SA) report high lower limb salvage rates in patients whose only other option was amputation, and its popularity has grown in Europe and elsewhere. However, despite some interest in the United States, intrainguinal arterial bypass surgery, intraluminal angioplasty, or, as a last resort, amputation remain the only options for American patients with severe peripheral vascular disease.

"[Subintimal angioplasty] is not used much at all in North America. It hasn't had enough exposure. It's a very simple, very cheap technique, with just a wire, catheter, and balloon. There are no lasers or expensive fibers, so there is no commercial interest in this for [medical equipment] companies, and therefore no promotion," said Dr. Bolia, head of vascular radiology at Leicester (England) University Hospital, where he developed the technique--by accident--in 1987.

SA came into being during a routine angioplasty, when Dr. Bolia unintentionally entered the subintimal plane of an occluded popliteal artery with a guidewire. The wire naturally formed a loop--which Dr. Bolia likens to the stripping ring used in an endarterectomy--and dissected the vessel's intimal and medial layers in a spiraling fashion, until it reentered the true lumen just distal to the occlusion. This subintimal channel was balloon dilated along its length, crushing and displacing the detached, atheromatous true lumen to one side of the vessel wall and creating a new lumen, which remained patent for more than 9 years.

Since then, the technique has expanded from the femoropopliteal segment to include infrapopliteal vasculature, and reconstitution of bi- and trifurcations, which Dr. Bolia noted as a major advantage over surgery.

"Surgeons can only manage to plug a graft onto one vessel. By reconstituting a trifurcation, we can save all three--the advantage being that when you recanalize, you save the popliteal artery. A grafted vessel, limited to a three-vessel run-off, clearly does not bode well for long-term patency," he said. In recent years, interest in SA has increased with the publication of several clinical studies underscoring the procedure's limb salvage rates--as high as 85%-90% at 1 year post procedure--though, as its detractors often point out, long-term patency rates tend to be relatively low, compared with surgical bypass rates.

Dr. Bolia discussed the results of a Norwegian study (Eur. J. Vasc. Endovasc. Surg. 2004;28:645-50) on the long-term patency rates of 116 SA procedures in 104 claudicants with femoropopliteal occlusions measuring an average of 16 cm. Technical success was achieved in 87% of patients, whereas primary assisted patency after 5 years was 64% in the 101 cases with successful recanalization, and 54% overall.

Despite the simplicity of the tools used, learning how to enter the subintimal plane and reenter the lumen without damaging collateral vessels is notoriously difficult for novices, and thus SA has been slow to acquire adherents. However, in European centers with extensive practical experience--such as Dr. Bolia's department at Leicester University Hospital, which has treated more than 45,000 cases--it has become the first-line treatment for critical limb ischemia.

Dr. Bolia stressed that, even in cases with low long-term patency, most patients remain asymptomatic and, in the event of initial treatment failure, the procedure can be repeated and patients can usually undergo bypass surgery, if necessary.

< previous article | Table of Contents | next article >

Society for Vascular Surgery - 633 N. St. Clair, 24th Floor; Chicago, IL 60611; Phone: 312-334-2300 or 800-258-7188; Fax: 312-334-2320; Email: vascular@vascularsociety.org
© 2010 VascularWeb. All rights reserved. Use of the VascularWeb site constitutes acceptance of all of the policies, rules and regulations for the site.