Subintimal Recanalization of Occlusive Femoropopliteal Lesions

Objectives: We sought to determine the feasibility of subintimal recanalization (SIR) for femoropopliteal occlusions.
Methods: All patients undergoing SIR, angioplasty, and selective stenting of their superficial femoral (SFA) and/or popliteal arteries between 2002 and 2006 at a single university hospital were retrospectively examined for demographics, procedural details, TASC scores, success rates, and patency rates. Patients were followed with serial physical exams and pulse volume recordings.
Results: 134 procedures were performed on 115 patients. Indications included progressive claudication (56%), rest pain (15%), and tissue loss (28%). Patients had a mean age of 68 ± 12 years; there were 54 men and 61 women. The treated lesions were classified according to TASC II: 40 A (31%), 50 B (39%), 19 C (15%), and 19 D (15%). The technical success rate was 89%. Patency rates could be determined for 104/134 procedures. Kaplan-Meier analysis revealed a mean primary patency of 1.5 years (95% CI 1.0-1.9), a mean assisted primary patency of 1.6 years (95% CI 1.1-2.0 years), and a mean secondary patency of 2.4 years (95% CI 1.9-2.8 years). Subsequent ipsilateral bypass was required in 15 patients. Eight patients eventually required ipsilateral amputation. Risk factors for restenosis or reocclusion were assessed by multivariate Cox regression, see Table. In particular, impaired runoff greatly increased the risk of restenosis/reocclusion. There was no 30-day perioperative mortality. In all cases the target reentry vessel was preserved so that future bypass options were not affected.
Conclusions: SFA and popliteal occlusions can be treated using SIR, angioplasty, and selective stenting with excellent technical success. Our data suggests that patients with impaired distal runoff will likely suffer diminished patency. Nevertheless, SIR should be considered as a first-line therapy for femoropopliteal occlusive lesions.