Subintimal stenting for superficial femoral artery long occlusion in patients with critical limb ischemia

Introduction: Subintimal recanalization of chronic totally occluded superficial femoral arteries (SFA) has gained increasing attention as an effective approach for limb salvage in patients with critical limb ischemia (CLI). Use of stents in treating SFA lesions has increased with the intention to improve arterial patency. Our aim was to evaluate the feasibility and mid-term outcomes of subintimal stenting in long occlusions of the SFA in patients presenting CLI. Methods: A retrospective review of consecutive patients admitted to our unit with chronic occlusion of the SFA and CLI between september 2008 and september 2010 was performed. Within this group, the subintimal angioplasty with primary stenting was used in 14 SFAs in 12 patients (10 men). The mean age was of 66.1 (range 57-80 )years; nine (75%) patients had diabetes mellitus and 3 (25%) were on chronic hemodialysis. Two of them were in Rutherford category IV, six in Rutherford category V and the remaining four patients were in Rutherford category VI (advanced foot gangrene). All patients had an ultrasound examination and preoperative mean ankle-brachial index (ABI) was 0.38 (range 0.23-0.61). Results: All procedures were performed in a dedicated endovascular suite under local anesthesia. The average length of SFA occlusions was 18.7 cm (range 10-35 cm). The target vessel was recanalized via a contralateral approach in all cases using standard subintimal technique. In one case was not possible to re-enter the looped wire into the true lumen. In this patient a re-entry device (Outback) was successfully employed to complete the procedure. The technical success rate of standard subintimal recanalization was of 91.7%. Eighteen Protégé Everflex stents were implanted (1.5 stent per patient) in 14 SFAs. No death occurred in the pe- rioperative period. The mean postoperative ABI increased to 0.59 (range 0.34-1). The six-months primary patency rate was 85.7%. Limb salvage (freedom from major amputation) was of 100% at a medium follow-up of 15.4 months (range 1-24 months). Conclusions: The subintimal angioplasty with routine stenting is a feasible and safe technique for long SFA occlusions even in patients with severe chronic CLI. This technique provides successful short-term primary patency and limb salvage.