SFA Intervention: Intraluminal or Subintimal?

Abstract

Subintimal angioplasty (SA) is an endovascular technique to recanalize an occluded arterial segment through an extraluminal channel between the intima and media. Since its introduction in 1989, the technical success rate has improved with the accumulation of procedural experience and the development of retrograde approaches and re-entry devices. To date, no randomized trial has compared SA with intraluminal angioplasty (IA) for chronic total occlusion (CTO) of the superficial femoral artery (SFA). Based on limited data from several registry studies, SA appears to achieve a higher technical success rate than IA, whereas mid-term primary patency rates are comparable for both endovascular wiring strategies for SFA CTO. Additional clinical data are needed to confirm that SA is as effective as IA. The optimal stenting strategy and role of drug-eluting technologies also need to be defined to improve SA outcomes.

Keywords: Angioplasty; Femoral artery; Peripheral artery disease; Popliteal artery.

Figure 1. A representative subintimal angioplasty case. (A) Baseline angiogram showing superficial femoral artery long occlusion. (B) A hydrophilic wire was introduced into subintimal space, and a wire loop was formed by advancing the wire into the subintimal channel. (C) Angiogram after pre-dilation. (D) Final angiogram after stent implantation.

Figure 2. Intravascular ultrasound images of an occluded superficial femoral artery segment before pre-dilation, after pre-dilation, and after stenting.

S = subintimal channel, TL = occluded true lumen.