2007 Abstracts: Subintimal Angioplasty for Revascularization after Failed Lower Extremity Bypass

Background: Percutaneous subintimal angioplasty (SIA) has gained popularity as an alternative to surgical bypass for lower extremity (LE) revascularization. Despite a growing body of literature supporting SIA as first line therapy there is limited data describing SIA after failed LE bypass. The current study was undertaken to evaluate the success of SIA of the native arterial circulation after failed LE bypass.
Methods: Patients undergoing SIA after failed LE bypass between 7/2004 and 6/2006 were identified from a vascular registry. Demographic data, surgical history, and procedural details were collected prospectively. Ultrasound follow-up with clinical correlation was performed at 6 weeks, and 3 and 6 months. Major amputation and death defined the primary endpoints with secondary endpoints defined by conversion to redo bypass, repeat endovascular intervention, recurrent ulceration/rest pain, and occlusion of the treated vessel.
Results: Twenty patients underwent SIA after failed LE bypass. The indications for the initial bypass included rest pain (n=10, 50%), ulceration (n=7, 35%), and claudication (n=3, 15%). Femoral-popliteal bypass had been performed in 55% (n=11) and femoral-tibial bypass in 45% (n=9). All patients presented with occlusion of the bypass and ulceration (n=9, 45%), rest pain (n=4, 20%), severe claudication (n=4, 20%), or gangrene (n=3, 15%). Mean ankle-brachial index (ABI) prior to SIA was 0.25. The technical success rate was 85% (17/20). Adjunctive stenting was required in 10 cases (50%) and laser atherectomy in 2 cases (10%). There were no immediate surgical conversions or peri-procedural complications. The mean ABI at 6 month follow-up was 0.76. Repeat endovascular therapy was required in 4 patients (20%). The 6 month primary-assisted patency was 80%. Eighteen (90%) patients were asymptomatic at 6 months with a limb salvage rate of 95% (n=19). Two patients underwent a redo lower extremity bypass and another patient required a below-knee amputation at 8 months post-intervention. Two patients (10%) died of unrelated causes at 7 and 9 months following the procedure.
Conclusions: Subintimal angioplasty offers a safe and effective endovascular option for lower extremity revascularization and limb salvage after failed LE bypass.