Subintimal Arterial Flossing With Antegrade-retrograde Intervention Research Articles

Technical Success, Midterm Primary Patency, and Factors Affecting Primary Patency of Subintimal Angioplasty Followed by Vasculomimetic Stenting for Trans-Atlantic Intersociety Consensus II C and D Femoropopliteal Arterial Disease—A Prospective Study

Abstract Background The best option among the endovascular options in long, complex femoropopliteal (FP) lesions, and factors affecting the patency have yet to be well described. There are few studies describing the mid- and long-term patency of endovascular stents in long-segment FP occlusions. Aim This study aimed to determine the technical success and mid-term patency of subintimal angioplasty with vasculomimetic stenting in Trans-Atlantic Inter-Society Consensus II (TASC) C and D FP disease. The patient and imaging factors that affect primary patency were also analyzed. Methods and Materials A single-center prospective study was performed on 52 consecutive patients undergoing endovascular treatment for TASC C and D FP disease from 2017 to 2021. Angioplasty with stenting was performed in all patients and followed up for 36 months. Endpoints were primary patency rates and amputation-free survival of the limb. Kaplan–Meier curves were used to see patency rates and amputation-free survival rates. Results A total of 52 patients underwent stenting with a technical success rate of 100% if the sub-intimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique was used. Primary stent patency at 6, 12, 18, 24, and 36 months was 89.8, 81.4, 76.2, 71.4, and 62.5%, respectively. Amputation-free survival was 98, 95.6, 91.8, and 85.7% at 12, 24, 30, and 36 months, respectively. Cox proportional regression analysis showed smoking and vessel wall calcium score more than 270 degrees as independent predictors of loss of primary patency (hazard ratio 0.35 confidence interval [CI]: 0.003–0.448) and 0.102 (CI: 0.022–0.47), respectively. Conclusion Subintimal angioplasty with vasculomimetic stent has good midterm patency in and amputation-free survival in long-segment FP occlusions. Smoking and severe vessel wall calcification adversely affect patency.

Application of the gunsight technique to facilitate subintimal arterial flossing with antegrade-retrograde intervention for the treatment of lower extremity chronic total occlusion

Objectives: Endovascular treatment of atheromatous chronic total occlusions (CTOs) of the lower extremity using the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) method may fail due to inability to position the antegrade and retrograde wires in the same plane. Failed attempted SAFARI in three limbs, in two patients, was rescued using a gunsight technique. Material and Methods: Retrospective procedure database review revealed three procedures where an occlusion could not be crossed despite antegrade and retrograde access which were treated using a novel technique for percutaneous puncture through antegrade and retrograde loop snares (gunsight technique). Results: Three limbs in two patients (mean age: 64 years) were treated using the gunsight technique. All three CTOs were successfully crossed and dilated with angioplasty and/or stents. A positive clinical outcome was achieved in each of the three affected limbs. Conclusion: The gunsight technique can improve technical success of SAFARI in the treatment of CTOs for atheroocclusive disease when there is failure to cross the lesion with standard endoluminal or subintimal approaches.

Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia

PurposeTo report the outcome and distal access patency of the Subintimal Arterial Flossing with Antegrade-Retrograde Intervention (SAFARI) technique for chronic total occlusion (CTO) in critical limb ischemia (CLI). Materials and MethodsFrom January 2009 to June 2015, 220 SAFARI procedures were performed for 200 limbs in 191 patients (108 males [56.5%]; median age, 70 years old; range, 36 to 97 years old) with CLI (9.4% were Fontaine classification 3; and 90.6% were Fontaine classification 4). Distal access was obtained from the distal superficial femoral artery (n = 6), popliteal artery (n = 49), anterior tibial artery (n = 56), dorsalis pedis (n = 51), peroneal artery (n = 12), posterior tibial artery (n = 45), and lateral plantar artery (n = 1). Distal access hemostasis was obtained with internal balloon tamponade in 71.4% (n = 157). Outcome measurements were technical success, freedom from major amputation and complications. Preprocedural angiograms of clinically driven repeat interventions were reviewed in 73 cases for distal access patency. ResultsTechnical success was achieved in 80.5% (n = 177). Reasons for technical failure include inability to obtain distal access (n = 3), cross the occlusion retrogradely (n = 16), re-enter the true lumen (n = 9), and achieve antegrade blood flow after the procedure (n = 15). Freedom from major amputation for technically successful procedures was 84.7%, 82.9%, and 81.9% at 6, 12, and 24 months, respectively. There were 3 cases of distal access bleeding with 1case that required coil embolization. The distal access remained patent in 80.8% of observable cases with repeated endovascular intervention. ConclusionsDistal retrograde arterial access (SAFARI) technique is safe and effective in the treatment of CTOs in the context of CLI, after failure of antegrade revascularization.

1:00 PM Abstract No. 5 - Assessment of safety of a single vessel runoff “peroneal artery access” during the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) in critical limb ischemia (CLI)

1:00 PM Abstract No. 5 - Assessment of safety of a single vessel runoff “peroneal artery access” during the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) in critical limb ischemia (CLI)

Abstract No. 424 - Angioplasty first approach to critical limb ischaemia (CLI): our experience with SAFARI (subintimal arterial flossing with antegrade-retrograde intervention) technique for infra-inguinal arterial occlusions

Review of angioplasty first approach to challenging infrainguinal occlusions using SAFARI technique. We have adopted an angioplasty first approach to critical limb ischemia in 2007. Infrainguinal, especially infrapopliteal intervention forms a large part of our CLI practice and most of these patients are diabetic. Chronic long segment calcified total occlusions of SFA and below knee vessels are not uncommon and are most challenging to manage endovascularly. In 2009 we started performing SAFARI technique for those lesions that failed antegrade recanalization and here, we review our experience with this approach. Data was collected from the Interventional Radiology section of our institute in Singapore. Between January 2009 to March 2013, 131 SAFARI procedures were performed in 117 patients (mean age: 70.7 years, range: 36 to 98 years, M:F 1:1) due to failure to cross lower extremity CTOs antegradely. All cases presented with critical limb ischemia (Fontaine III: 18, IV: 113). Proximal access was ipsilateral and contralateral common femoral artery in 109 and 22 procedures respectively. Distal retrograde access was obtained from the following arteries: popliteal (n=39), dorsalis pedis (n=28), anterior tibial (n=32), posterior tibial (n=21), peroneal (n=7), superficial femoral (n=3) and lateral plantar (n=1). Balloon assisted hemostasis was performed for distal retrograde punctures sites in 81 procedures. Mean follow up period was 5.4months (range 0.5 to 24.0 months). Very long segment (> 20cm) occlusions were seen in 51.9% of cases. Technical success was achieved in 107/131 (81.7 %) of procedures. A total of 156 limb segments were successfully recanalized with 63.4% limb salvage at 6 months. Causes of failure were inability to cross hard calcified plaques (8.3%), inability to reenter the true lumen after subintimal access (3.8%) and on-table reocclusion due to elastic recoil (2.2%). Major and minor complications were seen in 4 (3.1%) and 12 (9.1%) procedures respectively. There was no procedure related mortality. SAFARI technique in CLI is a safe and effective treatment option for difficult infra-inguinal lesions.

Abstract No. 89: Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for lower extremity chronic total occlusions

Abstract No. 89: Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for lower extremity chronic total occlusions

Regarding the “SAFARI” Technique: A Word of Caution

Recently a few authors have reported experience regarding the safety and efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) in patients with critical limb ischemia (CLI) presenting long occlusions involving the popliteal trifurcation. Spinosa et al. described the use of this technique in 20 limbs (21 cases), with a limb salvage rate of 90% at 6 months. The authors concluded that 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. Also, according to these authors the SAFARI technique improves technical success in the performance of subintimal recanalization, and limb salvage rates are comparable to those with antegrade subintimal recanalization [1]. Gandini et al reported the use of this novel technique in four out of 104 patients with CLI. In their paper those authors concluded that the SAFARI technique should be adopted as a ‘‘standard procedure’’ in CLI cases showing long occlusions involving the trifurcation and presenting risk of amputation [2]. While we agree with Spinosa et al. that the SAFARI technique should be adopted in the presence of failure to reenter the distal true lumen from an antegrade approach, we do not think that this technique should always be used as first choice in the presence of long occlusion involving the trifurcation. Indeed, the SAFARI technique is indubitably an attractive option but, in view of the limited number of cases reported in the literature, should not yet be regarded as a standard procedure. According to the literature [3–5], intraluminal or subintimal recanalization of long occlusions involving the popliteal trifurcation is normally achieved by the transfemoral approach. In the last 2 years more than 1000 diabetic patients with CLI have been successfully treated endovascularly at our two centers (Multimedica IRCCS, Milan, and Multimedica Santa Maria Hospital, Castellanza, Va.). In this large cohort of subjects the use of the SAFARI technique was deemed necessary in four cases only (one posterior tibial and three anterior tibial artery approaches) and, importantly, after unsuccessful repeated attempts at distal revascularization. To the present authors, direct puncture of the distal third of a calf artery is not free of serious complications, leading in certain instances to flowlimiting dissection (due to introducer sheath advancement or due to the puncture itself) as well as thrombosis of the accessed artery (mainly at the end of the intervention during manual compression of the puncture site). Also, as reported by Gandini et al., the ‘‘presence of ulcers at the entry zone is an important limitation to the performance of this type of approach.’’ Finally, this type of procedure is time-consuming, which is a main limitation in such critically ill patients (heart and renal comorbidities are often associated). In conclusion, at this moment in time the use of the SAFARI technique should not be regarded as the first option for the treatment of diabetic patients with CLI. In expert hands, however, it may be considered in selected cases, after unsuccessful attempts at revascularization from the femoral artery. Most importantly, when this novel approach is deemed necessary, surgical exposure rather T. Lupattelli (&) Department of Radiology and Interventional Radiology, Via milanese 300, Sesto San Giovanni, Milan 20099, Italy e-mail: tommasolupattelli@hotmail.com

Outback catheter-assisted simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion

Subintimal recanalization techniques have been shown to be beneficial in selected patients with severe peripheral vascular disease with tissue loss or rest pain and limited surgical options. In this report, we use an Outback catheter in order to gain access to the subintimal channel from the true lumen during percutaneous intentional extraluminal recanalization using the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique. To the best of our knowledge, this is the first report where the Outback catheter was used in antegrade fashion in order to gain access to the subintimal space from the true lumen using the SAFARI technique.

Subintimal Stent Placement in Patients with Long Segment Occlusion of the Iliac Artery

Purpose: We evaluated the technical feasibility and clinical efficacy of subintimal stent placement for long segment occlusion of the iliac artery. Materials and Methods: From March 2003 to February 2007, subintimal stent placement for long segment occlusion of the iliac artery of 24 limbs in 22 patients was analyzed retrospectively. Endovascular access was performed via the ipsilateral femoral artery in 7 cases, via the contralateral femoral artery in 6 cases, via both femoral arteries in 10 cases and via the brachial artery in one case. The SAFARI (subintimal arterial flossing with antegrade-retrograde intervention) technique using a microcatheter was performed to recannalize iliac artery occlusion in three cases. Medical records were reviewed for the collection of follow-up data. The stent patency rate was analyzed by use of the Kaplan-Meier method. Results: Subintimal stent placement was technically successful in 23 of 24 procedures (95.8%). The mean ankle-brachial index (ABI) increased from 0.26 to 0.82. The Fontaine classification was improved after stent placement in all patients. Major complications occurred in four procedures: three distal embolizations and one arterial rupture. All of the complications were successfully treated by endovascular intervention. The primary stent patency rates at 6-months, 1-, 2- and 3-years were 95%, 88%, 88% and 88%, respectively. Conclusion: Subintimal stent placement is a safe and effective treatment for long segment occlusion of the iliac artery.

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.

Subintimal Arterial Flossing with Antegrade–Retrograde Intervention (SAFARI) for Subintimal Recanalization to Treat Chronic Critical Limb Ischemia

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. 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. 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. 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.