Subintimal Snare Technique as a Safe and Reliable Means of Recanulating Chronic Total Occlusions of the Iliacs

BACKGROUND: An 87 year old female presents with a history of previous right to left femoral to femoral artery bypass grafting performed for claudication approximately two years prior at a small community hospital. Postoperative course was complicated by difficult wound healing of both groins. She now presents with purulent drainge from the left groin with evident infection of the prosthetic bypass material.
METHODS: Computed tomographic angiography shows chronic total occlusion (CTO) of the left common iliac artery (CIA) as seen previous to the extra-anatomical bypass procedure, as well as evidence of the infection incorporating the prosthetic femoral to femoral graft. Subsequent angiography was performed with recanulation of the chronically occluded left CIA. Access to the left iliac vasculature was obtained with a cutdown of the patent superficial femoral artery in the mid-thigh well removed from the infected left groin. Attempt to cross the CTO of the left CIA with antegrade and retrograde approach were both complicated by subintimal dissection planes extending beyond the intended treatment site. A subintimal snare technique was therefore incorporated. This involved snaring a glidewire passed antegrade from the right femoral access with a snare passed retrograde from the left femoral access. The actual snare was performed in the subintimal plane of the left CIA CTO. With successful crossing of the CTO now assured the lesion was treated with balloon mounted stenting resulting in an excellent angiographic and clinical result. The infected femoral to femoral bypass graft was subsequently removed with vein patch angioplasty of both common femoral arteries. The patient had an uneventful recovery and has healed all operative wounds with maintained normal perfusion to both lower extremities.
RESULTS: This case represents a modified endovascular option for treatment of an infected prosthetic graft. Other treatment options would pose significantly higher complication risks for this patient. The subintimal snare technique incorporated during this case has been reviewed since its inception (within the practice) approximately 26 months ago. During this time a retrospective analysis reveals that the primary author has treated 22 CTO's of CIA's. Five of these were crossed with relative ease with either direct antegrade or retrograde wire passage. The remaining 17 cases showed evidence of subintimal dissection beyond the target lesion with attempts at simple wire passage. The subintimal snare technique was therefore used in each case without failure. In all cases balloon mounted stents were used and successful recanulation was achieved. There were no complications involving extension of dissection beyond the treated lesions. All treatment sites have remained patent albeit for a fairly short follow-up period. Patent internal iliac arteries beyond the CIA CTO's have been spared with this technique.
CONCLUSIONS: The subintimal snare technique incorporated to cross and subsequently recanulate CTO's of CIA's has been shown to be reliable, safe, and thus far a durable means of treatment. This technique assures crossing of CTO's from true lumen above the lesion to true lumen below the lesion minimizing injury, or extension of dissection beyond the targeted treatment site.