Korean J Radiol.  2006 Jun;7(2):131-138. 10.3348/kjr.2006.7.2.131.

Subintimal Angioplasty in the Treatment of Chronic Lower Limb Ischemia

• Cho SK
• Doo YS
• Shin SW
• Park KB
• Kim DI
• Kim YW
• Kim DK
• Choo SW
• Choo IW

• KMID: 1782186
• DOI: http://doi.org/10.3348/kjr.2006.7.2.131

Abstract

OBJECTIVE
To present our experience with subintimal angioplasty (SA) for treatment of chronic lower limb ischemia (CLLI) and to assess its effectiveness and durability. MATERIALS AND METHODS: From April 2003 through June 2005, we treated 40 limbs in 36 patients with CLLI by SA. Balloons with or without secondary stent placement appropriate in size to the occluded arteries were used for SA of all lesions, except for iliac lesions where primary stent placement was done. The patients were followed for 1-23 months by clinical examination and color Doppler ultrasound and/or CT angiography. Technical results and outcomes were retrospectively evaluated. The presence of a steep learning curve for performance of SA was also evaluated. Primary and secondary patencies were determined using Kaplan-Meier analysis. RESULTS: Technical success was achieved in 32 (80%) of 40 limbs. There was no statistical difference between technical success rates of 75% (18/24) during the first year and 88% (14/16) thereafter. There were four complications (10%) in 40 procedures; two arterial perforations, one pseudoaneurysm at the puncture site, and one delayed hematoma at the SA site. Excluding initial technical failures, the primary patency rates at six and 12 months were 68% and 55%, respectively. Secondary patency rates at six and 12 months were 73% and 59%, respectively. CONCLUSION: Subintimal angioplasty can be accomplished with a high technical success rate. It should be attempted in patients with CLLI as an alternative to more extended surgery, or when surgical treatment is not recommended due to comorbidity or an unfavorable disease pattern.

Keyword

Arteries, extremities; Arteries, stenosis or obstruction; Arteries, subintimal angioplasty

MeSH Terms

Tunica Intima/pathology
Stents
Middle Aged
Male
Leg/*blood supply
Ischemia/epidemiology/*surgery
Intermittent Claudication/surgery
Humans
Female
Feasibility Studies
Constriction, Pathologic
Comorbidity
Chronic Disease
Angioplasty, Balloon/*methods
Aged, 80 and over
Aged

Figure

• 

  Fig. 1 A 63-year-old man who underwent subintimal angioplasty for an occluded left anterior tibial artery. There were unhealing ulcers of the 4-5th toes of left foot. A, B. Angiograms of left lower extremity show proximal occlusions of all tibial arteries (arrows) with reconstitution of the distal anterior tibial artery (arrowhead) above the ankle. C, D. After subintimal angioplasty of the occluded anterior tibial artery (not shown), the anterior tibial artery is successfully recanalized with good antegrade flow to the pedal artery (In figure D, the plane of view for the angiogram was right anterior oblique 16°). After SA, the ulcers healed completely and the patency of the treated left anterior tibial artery was maintained for three months until the time of investigation (not shown).

• 

  Fig. 2 A 76-year-old woman who underwent subintimal angioplasty for two separate occlusions involving the left superficial femoral and popliteotibial arteries. The lesions led to gangrene of the second toe of the left foot. A. Preprocedural angiogram of the left lower extremity shows long-segmental occlusion of the left superficial femoral artery, extending from the origin (arrow). B, C. After short segmental reconstitution of the left popliteal artery (arrows), downstream popliteotibial arteries are occluded with reconstitution of proximal anterior tibial artery (arrowheads D. The catheter and guide wire systems with a wire tip looping are passed along the subintimal plane to the occluded proximal anterior tibial artery. E-G. After subintimal balloon dilation, postprocedural angiograms show successful recanalization of the occluded superficial femoral artery and popliteotibial arteries with good antegrade flow to pedal artery. The patient underwent a planned metatarsophalangeal amputation three days after SA, with complete healing of the amputated site. Five months after SA, reocclusion of the treated arteries was found by color Doppler US (not shown). The patient was simply followed without any further treatment since she was asymptomatic.

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  Fig. 3 A graph shows the primary patency rates of subintimal angioplasty either on the basis of intention to treat or with technical success.

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