Subintimal angioplasty saves chronically ischemic limbs

Inoperable patients with chronic critical limb ischemia can avoid amputation by undergoing subintimal recanalization therapy, according to University of Virginia researchers.

Radiologists performing interventional subintimal angioplasty dissect the wall of the diseased vessel with a special guidewire. They then shove the balloon catheter through the subintimal space and create a new channel beneath the blocked or damaged area. The technique was introduced in England in 1989.

Research data indicate that subintimal angioplasty, with the aid of stenting when required, can reopen vessels up to 30 cm long.

Dr. David J. Spinosa and colleagues at the UV Health System, Charlottesville, treated 92 limbs facing certain amputation in 79 patients ruled unfit for infra-inguinal arterial bypass surgery. The patients either lacked the appropriate vessel structure required for the operation or suffered from significant conditions that rendered surgery too risky.

After treating the patients' superficial femoral and tibial arteries with subintimal angioplasty, the investigators found the technique highly successful in restoring blood flow and warding off amputation. They reported their findings at the Society of Interventional Radiology meeting in April.

Of the 92 limbs, 77% had tissue loss and 23% had rest pain alone. All limbs recovered blood flow after the procedure. The investigators compared two groups:

• Group 1: 65 limbs undergoing angioplasty and selective stenting smaller than 200 mm

• Group 2: 27 limbs undergoing angioplasty and selective stenting larger than 200 mm

Groups 1 and 2 showed a six-month limb salvage rate of 86% and 90%, respectively. The difference was not statistically significant.

The study suggests that interventional radiologists can apply the technique successfully in severe peripheral arterial disease, including minute vessels with long lesions, and save patients from amputations, Spinosa said.

The findings are particularly encouraging because patients with chronic limb ischemia who are candidates for bypass surgery normally face poor wound healing and increased risk of infection. These patients can now obtain less invasive treatment with subintimal angioplasty, he said.

"Knowing that we can offer potentially successful treatment for these long lesions in patients who typically have few options other than amputation is important," he said.

For more information from the Diagnostic Imaging archives:

Minimally invasive PVD treatment lowers amputation rates

Interventional conference scratches the surface of important issues

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