Subintimal Angioplasty for the Management of Chronic Total Occlusions

C hronic total occlusions of the femoropopliteal segments or infrapopliteal vessels are encountered more frequently with increasing patient longevity, bringing critical limb ischemia (CLI) to greater clinical attention. Surgical revascularization has been well documented for achieving limb salvage; however, the morbidity and mortality rate in this patient cohort can be significant.1 Endovascular therapy has been shown to be equivalent to surgical revascularization in achieving limb salvage with a favorable patient survival.2,3 Bolia first described subintimal angioplasty and has outlined its main purposes for the treatment of chronic limb ischemia.4-6 The value of subintimal angioplasty in limb salvage, and even comparison to bypass grafting, suggests that subintimal angioplasty may be a good first-line approach to long-segment occlusions in CLI and higher Rutherford category patients who are at above average risk for surgery.7,8 Bolia has described the subintimal angioplasty technique.9 This article describes the various techniques for subintimal angioplasty in more difficult applications used for 23 limbs in 20 patients for long-segment chronic total occlusion over the initial 9-month period the technique was started by a single operator. Indications primarily consisted of CLI (14 Rutherford category 5, four Rutherford category 4 and 5 for severe limiting claudication). Technical success was achieved in all cases. Four patients had flush occlusions, three patients had failed femoropopliteal bypass grafts, and only three patients required stent placement. Initiating the subintimal plane can easily be performed at occluded stumps or at the level of a large shelf-like plaque by pointing a catheter eccentrically away from the midline lumen. At times, a stiffer catheter (braided JR4, C.R. Bard Inc., Murray Hill, NJ, or other catheters) can be used, or heavy-duty straight wires such as the Newton wire (Boston Scientific Subintimal Angioplasty for the Management of Chronic Total Occlusions