The value of subintimal angioplasty in the management of critical lower extremity ischemia: failure is not always associated with a rethreatened limb

The technique of subintimal angioplasty was developed in Leicester, UK in 1987. Recently a growing number of centers in Europe and the United States have been gaining experience with this technique. Promising results have been reported and the application of the technique expanded to include the iliac and crural arteries. Despite this growing experience, the technique has not gained widespread acceptance. It has been speculated that this may be due in large part to a steep learning curve and/or skepticism regarding the procedure given the relatively low primary patency rates seen in most series. However, limb salvage rates from these same and other series have been considerably higher than the patency rates, and advocates of the technique have urged that the results of clinical series be viewed with these limb salvage rates primarily in mind. Although primary patency rates remain low for patients undergoing subintimal angioplasty limb salvage rates remain high. Given the many advantages of this technique, including reduced anesthesia requirements, a minimally invasive approach, and potential reductions in length of stay and cost subintimal angioplasty will continue to have a role in the treatment of lower extremity ischemia. When applied judiciously, bypass options are preserved. This does not mean that the availability of this technique should be used as justification to lower the threshold for the treatment of mild intermittent claudication. When a subintimal angioplasty fails, it frequently does so without the recurrence of symptoms, especially when a gangrenous lesion or ulcer has healed. Various approaches for the performance of subintimal angioplasty and clinical results will be discussed.