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Retrograde Pedal Access Technique for Revascularization of Infrainguinal Arterial Occlusive Disease. J Vasc Interv Radiol 2015; 26:29-38. [DOI: 10.1016/j.jvir.2014.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/07/2014] [Accepted: 10/10/2014] [Indexed: 11/18/2022] Open
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2
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Kawarada O, Sakamoto S, Harada K, Ishihara M, Yasuda S, Ogawa H. Contemporary crossing techniques for infrapopliteal chronic total occlusions. J Endovasc Ther 2014; 21:266-80. [PMID: 24754287 DOI: 10.1583/13-4460mr.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The synergism of technical refinement and advanced technology has significantly increased the popularity of infrapopliteal intervention. Since chronic total occlusion (CTO) is a common disorder among patients with symptomatic infrapopliteal artery disease, infrapopliteal CTO intervention is now evolving rapidly in the field of endovascular intervention. Guidewire crossing through the CTO is essential for a successful procedure. We review up-to-date infrapopliteal CTO crossing techniques based on the current literature.
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Affiliation(s)
- Osami Kawarada
- 1 Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Takama T, Hirano K, Nakano M, Iida O, Suzuki K, Miyashita Y, Ishimori H, Ito Y, Tsukahara R, Muramatsu T. Intravascular ultrasound findings after knuckle wire technique for superficial femoral artery occlusion. Interv Cardiol 2014. [DOI: 10.2217/ica.14.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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4
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Wrigley CW, Vance A, Niesen T, Grilli C, Velez JD, Agriantonis DJ, Kimbiris G, Garcia MJ, Leung DA. Endovascular recanalization of native chronic total occlusions in patients with failed lower-extremity bypass grafts. J Vasc Interv Radiol 2014; 25:1353-9. [PMID: 25060042 DOI: 10.1016/j.jvir.2014.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 06/05/2014] [Accepted: 06/05/2014] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts. MATERIALS AND METHODS Retrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication. RESULTS The mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively. CONCLUSIONS Endovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.
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Affiliation(s)
- Clinton W Wrigley
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Ansar Vance
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Timothy Niesen
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Christopher Grilli
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - J Daniel Velez
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Demetrios J Agriantonis
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - George Kimbiris
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Mark J Garcia
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718
| | - Daniel A Leung
- Department of Interventional Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, DE 19718.
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Ruzsa Z, Nemes B, Bánsághi Z, Tóth K, Kuti F, Kudrnova S, Berta B, Hüttl K, Merkely B. Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv 2013; 83:997-1007. [DOI: 10.1002/ccd.25262] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/05/2013] [Accepted: 10/14/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Zoltán Ruzsa
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
- Bács-Kiskun County Hospital; Teaching Hospital of the University of Szeged; Invasive Cardiology Department Kecskemét Hungary
| | - Balázs Nemes
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
| | - Zoltán Bánsághi
- Bács-Kiskun County Hospital; Teaching Hospital of the University of Szeged; Invasive Cardiology Department Kecskemét Hungary
- Saint-Imre Hospital; Teaching Hospital of the University Pécs; Radiology Department; Budapest Hungary
| | - Károly Tóth
- Bács-Kiskun County Hospital; Teaching Hospital of the University of Szeged; Invasive Cardiology Department Kecskemét Hungary
| | - Ferenc Kuti
- Bács-Kiskun County Hospital; Teaching Hospital of the University of Szeged; Invasive Cardiology Department Kecskemét Hungary
| | - Slavka Kudrnova
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
| | - Balázs Berta
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
| | - Kálmán Hüttl
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
| | - Béla Merkely
- Semmelweis University, Cardiac and Vascular Center; Budapest Hungary
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Sadaghianloo N, Jean-Baptiste E, Declemy S, Mousnier A, Brizzi S, Hassen-Khodja R. Percutaneous Angioplasty of Long Tibial Occlusions in Critical Limb Ischemia. Ann Vasc Surg 2013; 27:894-903. [DOI: 10.1016/j.avsg.2013.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 02/11/2013] [Indexed: 12/01/2022]
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Kota SK, Kota SK, Meher LK, Sahoo S, Mohapatra S, Modi KD. Surgical revascularization techniques for diabetic foot. J Cardiovasc Dis Res 2013; 4:79-83. [PMID: 24027360 DOI: 10.1016/j.jcdr.2012.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 10/14/2012] [Indexed: 10/26/2022] Open
Abstract
Diabetes is an important risk factor for atherosclerosis. The diabetic foot is characterized by the presence of arteriopathy and neuropathy. The vascular damage includes non-occlusive microangiopathy and macroangiopathy. Diabetic foot wounds are responsible for 5-10% of the cases of major or minor amputations. In fact, the risk of amputation of the lower limbs is 15-20% higher in diabetic populations than in the general population. The University of Texas classification is the reference classification for diabetic wounds. It distinguishes non-ischemic wounds from ischemic wounds which are associated with a higher rate of amputation. The first principles of treatment are the control of pain of an eventual infection. When ischemia is diagnosed, restoration of pulsatile blood flow by revascularization may be considered for salvaging the limb. The treatment options are angioplasty with or without stenting and surgical bypass or hybrid procedures combining the two. Distal reconstructions with anastomosis to the leg or pedal arteries have satisfactory limb-salvage rates. Subintimal angioplasty is a more recent endovascular technique. It could be suggested for elderly patients who are believed to be unsuitable candidates for a conventional bypass or angioplasty. The current article would focus on the various revascularization procedures.
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Affiliation(s)
- Siva Krishna Kota
- Department of Anesthesia, Central Security Hospital, Riyadh, Saudi Arabia
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Endovascular Treatment of Diabetic Foot in a Selected Population of Patients with Below-the-Knee Disease: Is the Angiosome Model Effective? Cardiovasc Intervent Radiol 2013; 36:637-44. [DOI: 10.1007/s00270-012-0544-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 12/01/2012] [Indexed: 11/26/2022]
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Schamp KB, Meerwaldt R, Reijnen MM, Geelkerken RH, Zeebregts CJ. The Ongoing Battle Between Infrapopliteal Angioplasty and Bypass Surgery for Critical Limb Ischemia. Ann Vasc Surg 2012; 26:1145-53. [DOI: 10.1016/j.avsg.2012.02.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 02/16/2012] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
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Alqahtani S, Kandeel AY, Rolf T, Frederic G, Qanadli SD. Case Report: An Unusual Combined Retrograde and Antegrade Transpedal Subintimal Recanalization of the Infrainguinal Arteries. J Vasc Interv Radiol 2012; 23:1325-9. [DOI: 10.1016/j.jvir.2012.06.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 06/22/2012] [Accepted: 06/27/2012] [Indexed: 10/27/2022] Open
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Rigatelli G, Cardaioli P, Dell'avvocata F, Giordan M, Lisato G, Mollo F. Endovascular management of patients with coronary artery disease and diabetic foot syndrome: A long-term follow-up. J Geriatr Cardiol 2012; 8:78-81. [PMID: 22783289 PMCID: PMC3390080 DOI: 10.3724/sp.j.1263.2011.00078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 06/08/2011] [Accepted: 06/15/2011] [Indexed: 12/05/2022] Open
Abstract
Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients (78.5 ± 15.8 years, 107 females, all with Fontaine III or IV class) who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease (CAD) and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure (TcPO2) before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%) and contralateral cross-over in 40/220 patients (18.8%) and popliteal retrograde + femoral antegrade in 10/220 patients (4.5%). Balloon angioplasty was performed in 252 legs (32 patients had bilateral disease): the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs (92.4%). Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ± 1.8 years (range 1 to 5 years) whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Intervention Unit, Rovigo General Hospital, Rovigo 45100, Italy
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Lee HJ, Park SW, Chang IS, Jeon HJ, Park JH. Strategies for successful percutaneous revascularization of chronic total occlusion of the femoropopliteal arteries when the antegrade passage of a guide wire fails. Korean J Radiol 2012; 13:467-75. [PMID: 22778569 PMCID: PMC3384829 DOI: 10.3348/kjr.2012.13.4.467] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/13/2011] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the efficacy of various strategies for revascularization of chronic total occlusion of femoropopliteal arteries when the guide wire does not pass in an anterograde direction. Materials and Methods Twenty-four patients with totally occluded femoropopliteal arteries (mean occlusion length 13.75 cm; range, 6-22 cm) were treated by using a retrograde approach and two novel catheters. After successful recanalization or reentry, balloon angioplasty followed by stent placement was performed to complete the revascularization. Results In 16 cases in which to cross the occlusion via intraluminal or subintimal route was failed, we used Frontrunner catheters in five cases and Outback catheters in 11 cases. In eight cases in which to reenter after subintimal passage of the guide wire was failed, we used Outback catheters. Successful recanalization was achieved intraluminally or subintimally in all cases. One perforation occurred during subintimal passage of the guide wire that was controlled by recanalization of another subintimal tract. There were no cases of distal thromboembolism or other complications. Conclusion A retrograde approach and using the Frontrunner and Outback catheters are safe and effective for successful revascularization of chronic total occlusion of femoropopliteal arteries. In particular, they are useful when the initial antegrade attempts at recanalization have failed.
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Affiliation(s)
- Hui Jin Lee
- Department of Radiology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul 143-729, Korea
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Setacci C, Sirignano P, Setacci F. Commentary: The ENABLER-P Balloon Catheter System: a new and exciting tool for recanalization of femoropopliteal CTOs. J Endovasc Ther 2012; 19:140-3. [PMID: 22545875 DOI: 10.1583/11-3664c.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Surgery, University of Siena, Siena, Italy.
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Ruzsa Z, Pintér L, Kolvenbach R. Retrograde transpedal stenting of the tibioperoneal trunk in critical limb ischemia. Catheter Cardiovasc Interv 2012; 80:1105-11. [DOI: 10.1002/ccd.23427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 10/17/2011] [Indexed: 11/06/2022]
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15
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Galassi AR, Tomasello SD, Costanzo L, Campisano MB, Barrano G, Ueno M, Tello-Montoliu A, Tamburino C. Mini-STAR as bail-out strategy for percutaneous coronary intervention of chronic total occlusion. Catheter Cardiovasc Interv 2012; 79:30-40. [PMID: 21956876 DOI: 10.1002/ccd.22998] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/14/2011] [Indexed: 01/27/2023]
Affiliation(s)
- Alfredo Ruggero Galassi
- Department of Internal Medicine and Systemic Disease, Clinical Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy.
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Gandini R, Uccioli L, Spinelli A, Del Giudice C, Da Ros V, Volpi T, Meloni M, Simonetti G. Alternative techniques for treatment of complex below-the knee arterial occlusions in diabetic patients with critical limb ischemia. Cardiovasc Intervent Radiol 2012; 36:75-83. [PMID: 22278664 DOI: 10.1007/s00270-012-0344-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/23/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The purpose of this study was to describe alternative endovascular (EV) techniques and assess their feasibility and efficacy in minimizing failure rates in limb salvage for the treatment of complex below-the knee (BTK) occlusions that could not be crossed with a conventional antegrade access. MATERIALS AND METHODS Between December 2007 and November 2010, 1,035 patients (557 male) underwent EV treatment for critical limb ischemia in our institution. In 124 (12% [83 male], mean age 68.2 ± 0.5 years) patients, transfemoral antegrade revascularization attempt failed, and an alternative approach was used. Follow-up was performed at 1 and 6 months. Results were compared with 56 patients treated between November 2002 and November 2007, in whom conventional technique was unsuccessful and unconventional techniques were not adopted. RESULTS Technical success was achieved in 119 (96%) patients. The limb-salvage rates were 96.8% and 83% at 1- and 6-month follow-up, respectively. Sixteen (12.9%) and 33 (26.6%) patients underwent reintervention at 1- and 6-month follow-up, respectively. Transcutaneous oxygen tension increased at 1 month (44.7 ± 1.1 vs. 15.7 ± 0.8 mmHg; p < 0.001) and remained stable at follow-up. Twenty (16.1%) patients required major amputation. Thirteen (10.4%) patients died during follow-up. In our previous experience, percutaneous transluminal angioplasty failure, amputation, and death rates were 10.9, 39.2, and 23.2%, respectively. Alternative techniques allowed a significant decrease of major amputation and death rates (p = 0.0001 and p = 0.02, respectively). CONCLUSION The use of alternative techniques seems feasible in case of a failed antegrade BTK revascularization attempt and could minimize failure rates in the treatment of complex occlusions while providing satisfying clinical success rates at 6 months.
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Affiliation(s)
- Roberto Gandini
- Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy, and Nuclear Medicine, IRCCS Policlinico di Tor Vergata, 00133, Rome, Italy
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Endovascular sharp recanalization for calcified femoropopliteal artery occlusion. Case Rep Cardiol 2012; 2012:516027. [PMID: 24826257 PMCID: PMC4008401 DOI: 10.1155/2012/516027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 07/18/2012] [Indexed: 11/17/2022] Open
Abstract
Endovascular intervention of peripheral chronic total occlusion (CTO) is technically challenging and time consuming. Various techniques and devices are used to facilitate lesion crossing and improve the success rate of the procedure. However, these new devices are quite expensive and not readily available. We report 2 cases of peripheral CTO wherein the occlusions were successfully crossed by using stiff end of Terumo glidewire. This sharp recanalization may be a useful technique for the recanalization of calcified peripheral CTOs when conventional techniques fail and new devices are not readily available, but it is accompanied by the risk of distal atheroembolism.
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CARDAIOLI PAOLO, RIGATELLI GIANLUCA, DELL’AVVOCATA FABIO, GIORDAN MASSIMO, LISATO GIOVANNA, MOLLO FRANCESCO, VASSILEV DOBRIN, NANJUNDAPPA ARAVINDA. Endovascular Treatment of Diabetic Foot Syndrome: Results from a Single Center Prospective Registry Using Mixed Coronary and Peripheral Techniques and Equipment. J Interv Cardiol 2011; 24:562-8. [DOI: 10.1111/j.1540-8183.2011.00676.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Ikushima I, Hirai T, Ishii A, Iryo Y, Yamashita Y. Confluent Two-Balloon Technique: An Alternative Method for Subintimal Recanalization of Peripheral Arterial Occlusion. J Vasc Interv Radiol 2011; 22:1139-43. [DOI: 10.1016/j.jvir.2011.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 04/06/2011] [Accepted: 04/07/2011] [Indexed: 11/25/2022] Open
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Pierret C, Tourtier JP, Bordier L, Blin E, Duverger V. [Subintimal angioplasty and diabetic foot revascularisation]. Presse Med 2010; 40:10-6. [PMID: 20980123 DOI: 10.1016/j.lpm.2010.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 08/15/2010] [Accepted: 09/06/2010] [Indexed: 01/17/2023] Open
Abstract
Diabetic wounds foot are responsible for 5-10% minor or major amputation in France. In fact, amputation risk of lower limbs is 15-30% higher for diabetic patients. University of Texas classification (UT) is the reference for diabetic foot wound. It distinguish non ischemic and ischemic wound with more amputation. If ischaemia is combined, revascularization may be considered for salvage of the limb. Some revascularization techniques are well known: as surgical by-pass, angioplasty with or without stent, or hybrid procedures with the both. Subintimal angioplasty is a more recent endovascular technique, in assessment for old patients who are believed to be unsuitable candidates for conventional by-pass or angioplasty.
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Affiliation(s)
- Charles Pierret
- HIA Val-de-Grâce, service de chirurgie viscérale et vasculaire, 75005 Paris, France.
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Choi SH. Current Management of Peripheral Arterial Disease. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2010. [DOI: 10.5124/jkma.2010.53.3.228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Seung-Hyuk Choi
- The Division of Cardiology, Department of Medicine, Sungkyunkwan University School of Medicine, Korea.
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Keeling AN, Khalidi K, Leong S, Wang TT, Ayyoub AS, McGrath FP, Athanasiou T, Lee MJ. Below knee angioplasty in elderly patients: predictors of major adverse clinical outcomes. Eur J Radiol 2009; 77:483-9. [PMID: 19765932 DOI: 10.1016/j.ejrad.2009.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 08/07/2009] [Accepted: 08/25/2009] [Indexed: 11/28/2022]
Abstract
AIM To determine predictors of clinical outcome following percutaneous transluminal angioplasty (PTA) in elderly patients with below knee atherosclerotic lesions causing intermittent claudication (IC) or critical limb ischaemia (CLI). MATERIALS AND METHODS Over 7.5 years, 76 patients (CLI 72%, n = 55) underwent below knee PTA. The composite end-point of interest was major adverse clinical outcome (MACO) of the treated limb at follow-up which was defined as clinical failure, need for subsequent endovascular or surgical revascularization or amputation. Actuarial freedom from MACO was assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression. RESULTS IC was improved in 95% at mean 3.4 years (range 0.5-108 months). Successful limb salvage and ulcer healing were seen in 73% with CLI. Most failures were in the CLI group (27% CLI vs. 5% IC), with an amputation rate of 16% for CLI vs. 5% for IC and persistent ulceration in 24% of CLI. Significant independent predictors of MACO were ulceration (hazard ratio 4.02, 95% CI = 1.55-10.38) and family history of atherosclerosis (hazard ratio 2.53, 95% CI = 1.1-5.92). CONCLUSION Primary below knee PTA is a feasible therapeutic option in this elderly population. Limb ulceration and family history of atherosclerosis may be independent predictors of adverse outcome.
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Affiliation(s)
- Aoife N Keeling
- Department of Academic Radiology, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland
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Keeling AN, Khalidi K, Leong S, Given MF, McGrath FP, Athanasiou T, Lee MJ. Subintimal Angioplasty: Predictors of Long-term Success. J Vasc Interv Radiol 2009; 20:1013-22. [DOI: 10.1016/j.jvir.2009.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 05/06/2009] [Accepted: 05/06/2009] [Indexed: 11/24/2022] Open
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Hussey KK, Hussey JK, Thorpe P, Brittenden J, Bachoo P. The role of subintimal angioplasty in the management of arterial disease of the lower limb: the North-East of Scotland experience. Surgeon 2008; 6:329-334. [PMID: 19110819 DOI: 10.1016/s1479-666x(08)80003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The management of occlusive femoropopliteal disease continues to evolve and a definitive strategy remains to be defined. We examine the utility ofsubintimal angioplasty (SIA) in our institution. METHODS A retrospective study with predefined end-points, including technical success and primary patency. RESULTS 61 consecutive cases were identified (claudicants n=29 and critical ischaemia n=32). Sixty-four percent of occlusions were greater than 10 cm with poor run-off (60% with two vessels or less). Technical and physiological success was 95% and 79% respectively, with clinical improvement reported by 72%. At a mean follow-up of 20 months twelve-month primary patency (assessed clinically, with ABPI and selective duplex scanning) was 67% (subgroup analysis: claudicants 83%, criticals 53%, p=0.02) and morbidity 8% with no limb loss or procedure related mortality. CONCLUSION SIA is an effective procedure for chronic lower limb ischaemia with acceptable outcome. Our experience correlates well with evidence in the current literature.
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Affiliation(s)
- K K Hussey
- Department of Surgery, Aberdeen Royal Infirmary, UK.
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Primary Infrainguinal Subintimal Angioplasty in Diabetic Patients. Cardiovasc Intervent Radiol 2008; 31:713-22. [DOI: 10.1007/s00270-008-9366-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 05/07/2008] [Accepted: 05/08/2008] [Indexed: 10/22/2022]
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Bozlar U, Shih MCP, Harthun NL, Hagspiel KD. Outback catheter-assisted simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. Clin Imaging 2008; 32:236-40. [DOI: 10.1016/j.clinimag.2007.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Accepted: 09/28/2007] [Indexed: 11/24/2022]
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Met R, Van Lienden KP, Koelemay MJW, Bipat S, Legemate DA, Reekers JA. Subintimal angioplasty for peripheral arterial occlusive disease: a systematic review. Cardiovasc Intervent Radiol 2008; 31:687-97. [PMID: 18414946 PMCID: PMC2515568 DOI: 10.1007/s00270-008-9331-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 02/27/2008] [Accepted: 02/28/2008] [Indexed: 12/02/2022]
Abstract
The objective of this study was to summarize outcomes of subintimal angioplasty (SA) for peripheral arterial occlusive disease. The Cochrane Library, Medline and Embase databases were searched to perform a systematic review of the literature from 1966 through May 2007 on outcomes of SA for peripheral arterial occlusive disease of the infrainguinal vessels. The keywords “percutaneous intentional extraluminal revascularization,” “subintimal angioplasty,” “peripheral arterial disease,” “femoral artery,” “popliteal artery,” and “tibial artery” were used. Assessment of study quality was done using a form based on a checklist of the Dutch Cochrane Centre. The recorded outcomes were technical and clinical success, primary (assisted) patency, limb salvage, complications, and survival, in relation to the clinical grade of disease (intermittent claudication or critical limb ischemia [CLI] or mixed) and location of lesion (femoropopliteal, crural, or mixed). Twenty-three cohort studies including a total of 1549 patients (range, 27 to 148) were included in this review. Methodological and reporting quality were moderate, e.g., there was selection bias and reporting was not done according to the reporting standards. These and significant clinical heterogeneity obstructed a meta-analysis. Reports about length of the lesion and TASC classification were too various to summarize or were not mentioned at all. The technical success rates varied between 80% and 90%, with lower rates for crural lesions compared with femoral lesions. Complication rates ranged between 8% and 17% and most complications were minor. After 1 year, clinical success was between 50% and 70%, primary patency was around 50% and limb salvage varied from 80% to 90%. In conclusion, taking into account the methodological shortcomings of the included studies, SA can play an important role in the treatment of peripheral arterial disease, especially in the case of critical limb ischemia. Despite the moderate patency rates after one year, SA may serve as a “temporary bypass” to provide wound healing and limb salvage.
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Affiliation(s)
- Rosemarie Met
- Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Kim JS, Kang TS, Ahn CM, Ko YG, Choi D, Jang Y, Chung N, Shim WH, Cho SY. Efficacy of Subintimal Angioplasty/Stent Implantation for Long, Multisegmental Lower Limb Occlusive Lesions in Patients Unsuitable for Surgery. J Endovasc Ther 2006; 13:514-21. [PMID: 16928168 DOI: 10.1583/05-1798mr.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To investigate the feasibility and clinical outcomes of subintimal angioplasty combined with stent implantation in patients with long, multisegmental occlusive lesions unsuitable for surgical treatment. METHODS Between 2003 and 2005, 30 patients (23 men; mean age 68 years, range 49-82) with severe claudication (Rutherford category 3, n=12) or critical limb ischemia (CLI; Rutherford category 4 or 5, n=18) underwent subintimal angioplasty with primary stenting for long (mean 28+/-11 cm) total occlusion in the lower limb arteries. Bypass surgery was considered unsuitable owing to inappropriate anatomy or poor distal runoff in 14 (47%) patients, severe coronary artery disease 14 (47%), or poor general condition in 2 (6%). RESULTS Technical success was achieved in 27 (90%) of 30 cases. The 3 technical failures were due to inability to advance the wire, to re-enter the distal lumen, and vessel rupture, respectively. Three (10%) complications occurred (1 perforation, 2 hematomas) but did not require surgery. After a mean follow-up of 13+/-7 months (range 3-28), 10 (37%) cases of restenosis were found in 27 patients. At 12 months, the primary patency rate was 52%, and the limb salvage rate was 83%. CONCLUSION Combined use of subintimal angioplasty and stent implantation was performed safely, with a relatively high success rate and acceptable intermediate-term clinical outcomes in patients with multisegmental, long occlusions of the lower limb arteries. Therefore, this strategy can be considered an option for symptomatic relief and limb salvage in patients unsuitable for bypass surgery due to various reasons.
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Affiliation(s)
- Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Center, Yonsei University College of Medicine, Seoul, Korea
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Karkos CD, Bright E, Bolia A, London NJM. Subintimal Recanalization of the Femoropopliteal Segment to Promote Healing of an Ulcerated Below-Knee Amputation Stump. J Endovasc Ther 2006; 13:420-3. [PMID: 16784332 DOI: 10.1583/05-1788.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To describe the use of the subintimal technique to revascularize an ulcerated below-knee amputation stump. CASE REPORT A 64-year-old man with persistent ulceration of a below-knee amputation stump underwent attempted percutaneous revascularization. Via antegrade puncture, the femoropopliteal occlusion was recanalized subintimally and eventually opened into a large medial geniculate collateral branch, improving the stump flow. The procedure was uneventful, and at 6 months, the patient was pain-free and able to mobilize with his prosthetic limb. CONCLUSION Subintimal revascularization of a critically-ischemic below-knee amputation stump may be a useful option and should be considered in clinical situations like this.
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Spinosa DJ, Harthun NL, Bissonette EA, Cage D, Leung DA, Angle JF, Hagspiel KD, Kern JA, Crosby I, Wellons HA, Hartwell GD, Matsumoto AH. Subintimal Arterial Flossing with Antegrade–Retrograde Intervention (SAFARI) for Subintimal Recanalization to Treat Chronic Critical Limb Ischemia. J Vasc Interv Radiol 2005; 16:37-44. [PMID: 15640408 DOI: 10.1097/01.rvi.0000141336.53745.4a] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To describe the technique of subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to improve technical success for the performance of subintimal recanalization when there is failure to reenter the distal true lumen or when there is a limited segment of patent distal target artery available for reentry. MATERIALS AND METHODS Subintimal recanalization was attempted in an antegrade direction in all patients. If reentry into the distal true lumen was unsuccessful or a short segment of target artery was present, retrograde access was obtained in the distal target artery (popliteal, anterior tibial/dorsalis pedis, or posterior tibial) and a retrograde subintimal channel was created. A guide wire was used to connect the retrograde and antegrade subintimal channels simultaneously to create a "flossing" guide wire. The subintimal tract was dilated with balloon angioplasty with or without stent implantation. Limb salvage, amputation-free survival, and survival rates over time were determined. RESULTS The SAFARI technique resulted in successful subintimal recanalization creating straight-line flow to the foot in all 21 limbs in 20 patients in which the technique was attempted. Antegrade-retrograde access was performed with the femoral artery and the following vessels: popliteal, n = 11; anterior tibial/dorsalis pedis, n = 10; and posterior tibial, n = 2 (two limbs involved multiple accesses). All procedures were successful. The limb salvage rate with SAFARI was 90% (95% CI, 74%-100%) at 6 months. CONCLUSIONS The SAFARI technique can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry. The SAFARI technique improves technical success in the performance of subintimal recanalization. Limb salvage rates are comparable to those with antegrade subintimal recanalization.
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Affiliation(s)
- David J Spinosa
- Fairfax Radiology Consultants, Inova Fairfax Hospital, Falls Church, Virginia, USA.
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Abstract
Infrapopliteal percutaneous transluminal angioplasty (PTA) is currently indicated in patients with critical limb ischaemia (CLI). It may be performed after femoral angioplasty or bypass surgery, to improve outflow and hence patency of the proximally treated segment. Patients with CLI are typically elderly with multiple co-morbidities and limited life expectancy and therefore, a procedure, which is minimally invasive with reduced morbidity and mortality but lesser long-term patency, may be more appropriate than a more invasive procedure with better long-term patency. Clinical success is superior to angiographic patency, because once healing has occurred, should the artery restenose or occlude, collateral flow can be sufficient to preserve tissue integrity if there is no further injury. Although no prospective randomized trials have been performed, the reported limb-salvage rates of PTA are comparable with surgery. As PTA carries a lower morbidity and mortality, shorter hospital stay and does not preclude surgery, it is ideal for this group of patients who are high-risk surgical candidates. Improvements in guide-wire and catheter technology and recanalization techniques mean that very long stenoses or occlusions, and multiple lesions can be treated successfully. At the current time, PTA is the treatment of choice for infrapopliteal occlusive disease; experience with the use of stents in this territory is increasing but currently insufficient to justify their primary use.
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Affiliation(s)
- D Tsetis
- Department of Radiology, St George's Hospital, Blackshaw Road, London SW17 0QT, UK
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Abstract
Subintimal angioplasty is a relatively new endovascular approach for the treatment of patients with femoropoliteal or tibial artery occlusion. The procedure involves intentionally creating a false channel or dissection around an arterial occlusion, then reentering the true lumen distally. The procedure has a relatively low incidence of complications and a high rate of technical success.Short-term patency has been fair in some reports and poor in others. Long-term results are not available. Aspirin and possibly anticoagulation or antiplatelet agents may improve technical success and short-term patency. Further studies with longer follow-up are required before it can be recommended as a potentially viable alternative to arterial bypass.
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Affiliation(s)
- Gerald S Treiman
- Veterans Affairs, Salt Lake City Health Care System, Surgical Care Center (112), 500 Foothill Drive, Salt Lake City, UT 84148, USA.
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Spinosa DJ, Leung DA, Matsumoto AH, Bissonette EA, Cage D, Harthun NL, Kern JA, Angle JF, Hagspiel KD, Crosby IK, Wellons HA, Tribble CG, Hartwell GD. Percutaneous Intentional Extraluminal Recanalization in Patients with Chronic Critical Limb Ischemia. Radiology 2004; 232:499-507. [PMID: 15286320 DOI: 10.1148/radiol.2322030729] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To review percutaneous intentional extraluminal recanalization (PIER) for treatment of patients who are poor candidates for infrainguinal arterial bypass surgery (IABS) and have arterial occlusions and chronic critical limb ischemia (CCLI). MATERIALS AND METHODS Patients with CCLI who were poor candidates for IABS were candidates for PIER. PIER was performed to create continuous arterial flow to the foot for limb salvage. PIER was attempted in 40 patients (22 men, 18 women; median age, 69 years; age range, 44-87 years). Of these patients, 24 (60%) had diabetes, 17 (42%) had renal disease, and 26 (66%) had coronary artery disease. Wound healing was evaluated at follow-up. Kaplan-Meier curves were constructed to evaluate limb salvage, survival, and amputation-free survival. RESULTS Fifty procedures were attempted in 44 limbs. Tissue loss was present in 40 (91%) limbs, and rest pain was present in four (9%); technical success occurred in 38 (86%). Thirty-seven (84%) of 44 limbs treated with PIER involved tibial vessels (tibial vessels only, n = 15; tibial and superior femoral artery [SFA] and/or popliteal vessels, n = 22). Sixty-six infrainguinal arterial vessel segments (SFA, n = 29; tibial, n = 37) in 38 limbs (1.7 segments per limb) were successfully treated with PIER. Thirty-five (95%) of 37 tibial occlusions and 24 (83%) of 29 SFA and/or popliteal occlusions were longer than 10 cm. Median run-off scores were 5.3 (range, 3-8) and 6.6 (range, 3-9) for patients with tibial occlusions and SFA and/or popliteal occlusions, respectively, as scored with modified Rutherford weighting of run-off arteries. Median follow-up was 7.8 months (range, 1-24 months). Twelve months after PIER, Kaplan-Meier analysis showed limb salvage rate was 66%, survival rate was 71%, and amputation-free survival rate was 48% in these patients. The 30-day mortality rate was 2.5%. Major complications occurred in four (10%) patients, and minor complications occurred in an additional four (10%). CONCLUSION PIER is a useful percutaneous technique for limb salvage in patients with CCLI.
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Affiliation(s)
- David J Spinosa
- Department of Radiology, University of Virginia Health Science Center, PO Box 170, Charlottesville, VA 22909, USA.
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Nadal LL, Cynamon J, Lipsitz EC, Bolia A. Subintimal angioplasty for chronic arterial occlusions. Tech Vasc Interv Radiol 2004; 7:16-22. [PMID: 15071776 DOI: 10.1053/j.tvir.2004.01.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percutaneous treatment of peripheral arterial disease has evolved greatly. The prevalence of superficial femoral artery occlusions has necessitated new devices and techniques to treat these patients percutaneously. Presently several therapies are available or under investigation. These range from stents, drug eluting stents, covered stents, cryoangioplasty, laser recanilization, blunt micro dissection, and subintimal angioplasty. This paper will discuss the indications, technique, and results of subintimal angioplasty.
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Affiliation(s)
- Luis L Nadal
- Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
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Reekers JA. Subintimal PTA: The Elegant Solution. J Vasc Interv Radiol 2004. [DOI: 10.1016/s1051-0443(04)70167-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Spinosa DJ, Leung DA, Harthun NL, Cage DL, Fritz Angle J, Hagspiel KD, Matsumoto AH. Simultaneous Antegrade and Retrograde Access for Subintimal Recanalization of Peripheral Arterial Occlusion. J Vasc Interv Radiol 2003; 14:1449-54. [PMID: 14605112 DOI: 10.1097/01.rvi.0000096764.74047.21] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Subintimal recanalization can be a useful procedure in selected patients with severe peripheral vascular disease with tissue loss or rest pain and limited surgical bypass options. Technical failure occurs in approximately 20% of patient who undergo percutaneous intentional extraluminal recanalization due to inability to reenter the distal true lumen. A technique to improve technical success when performing subintimal recanalization when there is failure to reenter the distal true lumen or possibly when there is a limited segment of patent distal target vessel for reentry is proposed. Further evaluation of this technique is necessary to confirm its safety and determine its technical and clinical success.
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Affiliation(s)
- David J Spinosa
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
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