SUBINTIMAL ANGIOPLASTY

Subintimal Angioplasty performed by creating a channel between the intima and the media by means of an intentional dissection and then to perform an angioplasty on this channel to enlarge it and maintain patency.

Indications

• Chronic occlusive arterial disease

• Failed percutaneous transluminal angioplasty (PTA)

• Dissection of native vessel in the presence of an occluded bypass graft

• Long diffuse stenotic disease, particularly in calcified vessels where the long-term patency of PTA is poor

• Flush SFA occlusions where PTA is likely to be impossible

• Reconstructing run-off vessels in the presence of popliteal or trifurcation occlusion

 

                                           SFA and Popliteal occlusion with gangrenoeus foot

                                                          Popliteal occlusion with rest pain

Technique

• Puncture  is  usually  antegrade  SFA  puncture

• A catheter is introduced proximally to the occlusion.

• Catheters

         4F  short catheter with an angled tip
            (Bolia mini-catheter, Terumo, Japan) is used.
        A 5F  pre-dilating straight catheter
             (Van Andel catheter, Cook, UK)
        5F  Cobra catheter may also be used

• Hydrophilic angle tipped  guide wire.

• Baloon catheter of appropriate diameter inflated with 10-12 atm pressure.

Drugs

• Prior to dissection 3000-5000iu intra arterial bolus of heparin is administered.

• Vasodilaters like nitrates or tolazoline.

• Premedicated with aspirin.

• Clopidogrel stopped 7 days prior.

Complications

• Haematoma    - Local             Retroperitoneal

• Peripheral embolism.

• Vessel perforation

• Elastic recoil -treated  vasodilators.

Limitations

• Fresh occlusions

• Heavy plaque Ca++

• Fine cylindrical Ca++

• Extensive diffuse disease

• Common femoral occlusions

Conclusion
A valuable technique that offers:
–  Scope of treatment
–  Long term patency
–  Success with less complication rate
–  Major impact on CLI