Cardiovasc lntervent Radiol 1199(1J 13:357-363

CardioVascular Inter nfional

Radio y

9 Springer-Verlag New York Inc. 1990

Aorta~Peripheral Arteries Percutaneous Transluminal Angioplasty of Occlusions of the Femoral and Popliteal Arteries by Subintimal Dissection A. Bolia, ~ K . A . M i l e s , ~ J. B r e n n a n , : and P . R . F . Bell e ' Department of Radiology. t.eicester Royal Infirmary, Leicester, England: and : Department o1"Surgery, University of Leicester, Leicester. England

Abstract. A t e c h n i q u e for r e c a n a l i z a t i o n o f f e m o r a l and p o p l i t e a l a r t e r i a l o c c l u s i o n s by intentional subintimal d i s s e c t i o n is d e s c r i b e d . R e c a n a l i z a t i o n with this t e c h n i q u e w a s a t t e m p t e d in 71 o c c l u s i o n s o f the f e m o r o - p o p l i t e a l s e g m e n t with a mean length o f 11.4 cm. P r i m a r y t e c h n i c a l s u c c e s s was a c h i e v e d in 54 (76%) c a s e s , with c o m p l i c a t i o n s o c c u r r i n g in 4 (5.6%). Of 44 s u c c e s s f u l c a s e s r e v i e w e d at a m e a n follow up o f 6 m o n t h s , 37 (84%) w e r e e i t h e r a s y m p t o m a t i c or i m p r o v e d . T h e t e c h n i q u e has p r o v e d to be an e f f e c t i v e m e t h o d o f t r e a t i n g b c c l u s i o n s o f the f e m o r a l a n d p o p l i t e a l a r t e r i e s with an a c c e p t a b l e c o m p l i c a t i o n rate. It m a y a l l o w s u c c e s s f u l angiop l a s t y w h e r e the s t a n d a r d i n t r a l u m i n a l m e t h o d fails, p a r t i c u l a r l y w h e n r e c o n s t r u c t i v e s u r g e r y is the o n l y option.

Key words: A n g i o p l a s t y - - F e m o r o p o p l i t e a l

t e c h n i q u e has n e v e r b e e n s y s t e m a t i c a l l y a p p l i e d to arterial occlusions. S u c c e s s f u l r e c a n a l i z a t i o n o f an o c c l u d e d f e m o ral a r t e r y w a s a c h i e v e d in o n e p a t i e n t (index c a s e ) while u n i n t e n t i o n a l l y p a s s i n g into the s u b i n t i m a l s p a c e a n d b a c k into the true lumen distal to the o c c l u s i o n . T h e a n g i o p l a s t y b a l l o o n was inflated w i t h i n the s u b i n t i m a l s p a c e a l o n g the w h o l e length o f the lesion a n d a g o o d result w a s a c h i e v e d w i t h o u t c o m p l i c a t i o n . F o l l o w i n g this o b s e r v a t i o n , a technique o f i n t e n t i o n a l s u b i n t i m a l p a s s a g e was d e v e l o p e d for t r e a t m e n t o f long o c c l u s i o n s o f the f e m o r a l a n d p o p l i t e a l a r t e r i e s . In the i n d e x c a s e and all subs e q u e n t p a t i e n t s 7 F c a t h e t e r s a n d 0.035 inch guidew i r e s w e r e u s e d . D e t a i l s o f t h e t e c h n i q u e a n d its r e s u l t s are d e s c r i b e d .

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sions--Subintimal dissection

Patients and Methods I n d e x Case

P e r c u t a n e o u s t r a n s l u m i n a l a n g i o p l a s t y ( P T A ) has b e c o m e an a c c e p t e d t e c h n i q u e for the t r e a t m e n t o f s t e n o s e s a n d o c c l u s i o n s o f t h e f e m o r a l and p o p l i t e a l a r t e r i e s . P r i m a r y s u c c e s s a n d long t e r m patency+are h o w e v e r g r e a t e r for s t e n o s e s than o c c l u s i o n s a n d p o o r e s t for long o c c l u s i o n s , p a r t i c u l a r l y w h e n l o n g e r than 10 c m [1]. O n e o f the m o s t c o m m o n c a u s e s of p r i m a r y failure is s u b i n t i m a l p a s s a g e of the g u i d e w i r e o r c a t h e t e r [2], g e n e r a l l y c o n s i d e r e d to be an i n d i c a t i o n for a b a n d o n i n g the p r o c e d u r e to a v o i d d i s s e c t i o n o f the a r t e r y . S u c c e s s f u l angiop l a s t y m a y on o c c a s i o n be a c h i e v e d by a c c i d e n t a l s u b i n t i m a l d i s s e c t i o n , but i n t e n t i o n a l use o f the

Address reprint requests to.' A. Bolia. M.D., Department of Radiology, Leicester Royal Infirmary, Infirmary Square. Leicester LEI 5WW. England

A 58-year-old man presented with an 18 month history of intermittent claudicatJon at I00 meters. He gave a history of smoking 12 cigarettes a day for several years but was not hypertensive or diabetic. He had mild hyperlipidemia and had suffered a recent myocardial infarction. A diagnostic angiogram demonstrated a 15 cm occlusion of the left superficial femoral artery (Fig. IA). An ipsilateral antegrade puncture was made into the common femoral artery and the occlusion was crossed using a straight 0.035 inch guidewire and a 7F predilating catheter, after instillation of 5,000 i.u. of heparin into the artery. During passage Qf the guidewire and subsequent injection of contrast, it became evident that the catheter had passed into the subintimal space. Despite this, the procedure was continued. A small false aneurysm was created but an intraluminal position was achieved distal to the occlusion. Balloon dilatation was performed using a 7F, 6 mm diameter catheter. An immediate postangioplasty arteriogram showed that the artery had been recanalized by subintimal passage of the catheter and guidewire (Fig. IB) with good flow of contrast through the false lumen. Aspirin (300 mg daily) was prescribed for three months following the procedure.

358

A. Bolia et al.: Angioplasty by Subintimal l)issectir

Fig. 1. A n g i o g r a m s from the index case: A before angioplasty. B immediately postangioplasty (note the small false a n e u r y s m of no c o n s e q u e n c e {arrow)), anti C three m o n t h s after a n g i o p l a s t , . ]'he recanalized segment is significantly wider than the vessel above and below due to the greater potential size of the subintimal space.

Fig. 2. Successfifl subintimal recanalization: A The dissection was intentionally proximal to the origin of the collateral (arrow) to avoid recurrent entry into the collateral by the guidewire or cathe~ter, B contrast injection intr the false lumen. C guidewire coiled within the false lumen, and D immediately postangioplasty. Note the eccentric subintimal channel (arrow) and the entry point (open arrow) into the true lumen distally.

The patient's s y m p t o m s were improved without complications and he had remained well when at 3 months a repeat angiogram d e m o n s t r a t e d that the artery was still patent (Fig. IC). The patient has remained s y m p t o m free on follow up at 32 months.

Patients Following the experience from this index case. a technique of recanalization by subintimal passage of the guidewire and catheter was developed. Initially. the procedure was performed only if the guidewire entered the subintimal space accidentally. In these circumstances, rather than abandon the attempt at recanalization. the procedure was continued via the subintimal route. Later, in s o m e c i r c u m s t a n c e s , deliberate attempts were made to enter the subintimal space with the intent of performing subintireal recanalization.

Clinical a s s e s s m e n t of the patients included history, examination, and Doppler ankle pressure m e a s u r e m e n t s before angioplasty and at follow up. 1-he presence of predisposing factors such as smoking and diabetes mellitus were sought and the indication for angioplasty (i.e.. claudication, rest pain. or ischemia) recorded. AIt patients had diagm)stic angiography by contralateral femoral arterial cannulation (unless previous surgery limited groin access) and only those patients with occlusions of the temoro-popliteal s e g m e n t are included in ~he study.

Techniq.e Indications The indications for subintimal recanalization comprised I~ accidental subintimal passage. 2) a long (e.g.. greater than 15 cm) and

A. Bolia et al.: Angioplasty by Subintimal Dissection

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