Reinterventions After Subintimal Angioplasty: The Need for Maintenance Therapy

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Gregory C. Schmieder, MD, Albert I. Richardson, MD, Eric C. Scott, MD, Andre Biuckians, MD, George H. Meier, III, MD, Jean M. Panneton, MD.
Eastern Virginia Medical School and Vascular & Transplant Specialists, Norfolk, VA, USA.

OBJECTIVES: With increased use of subintimal angioplasty (SIA), the role of reintervention after recurrence of lower extremity disease is currently unknown. To more clearly define the technical feasibility, patency, and clinical outcome of reinterventions after SIA, we reviewed our cumulative experience.
METHODS: A retrospective review of all patients who underwent reinterventions after primary SIA at our institution was performed. Patient history, demographics, procedural details, and follow-up information were collected and analyzed. Patency and limb salvage were determined by Kaplan-Meier analysis.
RESULTS: From December, 2002, through July, 2006, 490 lower extremity SIAs were performed. Of this cohort, 123 patients required 126 consecutive, first reinterventions. Technical success was achieved in 94% (n=118) of the procedures. Mean follow-up was 8.4 months (range, 0-34 months). The patency at 1 year for the first reintervention was 34%. Univariate analysis displayed a worse patency for reinterventions performed within 3 months of the primary SIA versus after 3 months (21% vs. 35%; p=0.04). Univariate analysis also demonstrated trends for better patency in patients undergoing reintervention for stenosis versus occlusion (p=0.11), males versus females (p=0.11), & isolated SFA lesions versus multiple segments (p=0.08). Other demographic or procedural variables did not significantly affect patency. The limb salvage at 1 year was 72%.

CONCLUSIONS: Endovascular reintervention after SIA is a safe and technically feasible procedure for recurrences and offers an excellent limb salvage rate. Early reinterventions performed within 3 months of the original SIA portend a worse outcome. In addition, female patients or patients with multiple, segmental recurrence may have worse outcomes after reintervention. Finally, by identifying a recurrent stenosis instead of an occlusion, close surveillance may contribute to improved overall outcome.

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