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Subintimal Angioplasty Track of the Superficial Femoral Artery

2012; Lippincott Williams & Wilkins; Volume: 5; Issue: 1 Linguagem: Inglês

10.1161/circinterventions.111.967026

1941-7632

Vincent P.W. Scholtes, Gert J. de Borst, Jean‐Paul P.M. de Vries, Frans L. Moll, Gerard Pasterkamp, Maurice A. A. J. van den Bosch, Aryan Vink,

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HomeCirculation: Cardiovascular InterventionsVol. 5, No. 1Subintimal Angioplasty Track of the Superficial Femoral Artery Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBSubintimal Angioplasty Track of the Superficial Femoral ArteryA Histological Analysis Vincent P.W. Scholtes, MD, Gert Jan de Borst, MD, PhD, Jean-Paul P.M. de Vries, MD, PhD, Frans L. Moll, MD, PhD, Gerard Pasterkamp, MD, PhD, Maurice A.A.J. van den Bosch, MD, PhD and Aryan Vink, MD, PhD Vincent P.W. ScholtesVincent P.W. Scholtes From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). , Gert Jan de BorstGert Jan de Borst From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). , Jean-Paul P.M. de VriesJean-Paul P.M. de Vries From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). , Frans L. MollFrans L. Moll From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). , Gerard PasterkampGerard Pasterkamp From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). , Maurice A.A.J. van den BoschMaurice A.A.J. van den Bosch From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). and Aryan VinkAryan Vink From the Laboratory of Experimental Cardiology (V.P.W.S., G.P.), Department of Vascular Surgery (G.J.B., F.L.M.), Department of Radiology (M.A.A.J.B.), and Department of Pathology (A.V.), University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Vascular Surgery, St Antonius Hospital, Nieuwegein, The Netherlands (J.-P.P.M.V.). Originally published1 Feb 2012https://doi.org/10.1161/CIRCINTERVENTIONS.111.967026Circulation: Cardiovascular Interventions. 2012;5:e6–e8IntroductionSince it was first described in 1990, subintimal angioplasty (SIA) has proven to be a valuable alternative for bypass surgery in patients with atheroocclusive disease of the superficial femoral artery (SFA).1 In this minimally invasive technique, a guidewire is intentionally placed between the intima and the media to create a new track along the vessel wall, bypassing the atherosclerotic occlusion.2 However, to our knowledge, the exact route of this subintimal track has never been confirmed with histopathology.There have been debates about the exact route of the guidewire during this procedure. Bolia et al2 were the first to report on this technique and emphasized that during subintimal passage, the guidewire does not pass the medial layer. On the other hand, Reekers et al3 observed that large, extensive, medial calcifications often result in the inability to perform this technique and concluded that the passage through the medial layer is necessary. Reekers et al, therefore, preferred to call this technique percutaneous intentional extraluminal revascularization.In this case report, we present a patient from whom an endarterectomy specimen of an occluded SFA was obtained 2 months after an SIA procedure, which gave the unique opportunity to study the exact route of the subintimal track using histopathology.CaseA 68-year-old woman was referred to our clinic with necrotic wounds around a former (traumatic) right-sided hallux amputation wound. Pulsations of the popliteal, anterior tibial, and dorsal pedic arteries were absent. Contrast-enhanced magnetic resonance angiography 8 weeks before the procedure revealed multiple pinpoint stenoses of a nearly occluded SFA.A schematic summary of the SIA procedure is depicted in Figure 1. After introduction of a 6-F sheath by retrograde puncture of the contralateral femoral artery, a diagnostic angiogram revealed that the stenoses had progressed to a total occlusion of the entire SFA (Figure 2A). An SIA procedure was performed; Figure 2B and 2C show the loop formed by the 0.035 guidewire within the subintimal space of the SFA, creating a novel track. This track was dilated with a 3 and 4 mm balloon; Figure 2D demonstrates the post-SIA situation, with a patent subintimal track and outflow of contrast into the popliteal artery toward the trifurcation, enabling bypass of the occluded segment.Download figureDownload PowerPointFigure 1. Schematic overview of a subintimal angioplasty procedure. A, Artery with occluding atherosclerotic plaque in the lumen (dark gray), internal elastic lamina (black), and media (gray). B through D, An angle-tipped guidewire is introduced into the subintimal space (B) and encouraged to form a loop by moving the catheter tip downward (C), enabling expansion of the subintimal track (D). E, Reentry of the true arterial lumen distal of the occlusion. F, Final result, with blood bypassing the occluded artery through the subintimal neolumen. Cross-sections of the occluded artery and the occluded artery with an open subintimal track are depicted above A and F.Download figureDownload PowerPointFigure 2. Contrast angiography during the subintimal angiography procedure. A, Situation at the beginning of the procedure with a total occlusion of the superficial femoral artery (SFA) (2) and an open profundic femoral artery (3). The tip of the guidewire (*) is located within the common femoral artery (1). B and C, Situation just after the creation of a neolumen or subintimal track. The tip of the guidewire (†) is located in the distal SFA, subintimally. D, Demonstration of the post-SIA situation, with a patent subintimal track and outflow of contrast in the SFA (4) and popliteal artery (5) toward the trifurcation, enabling bypass of the occluded segment. The angioplasty balloon is visible at the proximal part of the SFA (‡).Postprocedurally, the patient received clopidogrel and calcium carbasalate. The necrotic wounds did not show any healing tendency; therefore, 2 months later, a remote endarterectomy of the SFA was performed.4 The entire intimal core (including the atherosclerotic plaque and parts of the media of the vessel wall) of the SFA were dissected (Figure 3). The intimal core (length, 28 cm) was cut into segments of 1 cm, and every segment underwent histological study (Figure 3). In this way, we were able to reconstruct the track of the guidewire of the SIA procedure through the arterial wall.Download figureDownload PowerPointFigure 3. The entire resected intimal core is depicted at the left; the proximal part is marked with a suture. Histology of segments taken at a distance of 2, 12, 16, and 21 cm is demonstrated. Sections on the left are stained with elastic Van Giesson; consecutive sections on the right are stained with hematoxylin and eosin. The true lumen of the superficial femoral artery is almost occluded within 3 segments (*) but is open at 16 cm distance (†). The occluded subintimal track can be seen at distances of 12, 16, and 21 cm, as demonstrated by the presence of an organized thrombus (‡). Bar=1 mm. Magnification at 30×.Histology at multiple levels revealed a dissection of the arterial wall located between the internal elastic lamina and the atherosclerotic plaque (Figure 3). The newly formed route in the arterial wall was filled with thrombus at all levels. This observation confirms the early reobstruction of the SIA track and could explain the lack of postprocedural healing tendency. At distal levels, the thrombus showed more signs of organization than proximally, suggesting that the obstruction of this newly formed lumen began at the distal part of the artery. The true lumen of the artery focally was totally occluded by the atherosclerotic plaque, compatible with the observed occlusion before the SIA procedure.DiscussionTo our knowledge, this is the first time the track of a guidewire after a recent SIA procedure of the SFA was studied using histology to visualize the exact route of the newly developed subintimal neolumen. Important morphological changes following transluminal angioplasty have been described, but histology following SIA has not been reported. We report that the subintimal track had been formed between the internal elastic lamina and the atherosclerotic plaque at most levels. This single-case study confirms the idea that SIA is not a random extraluminal revascularization procedure but creates subintimal passage in the form of a dissection between the atherosclerotic plaque and the media of the artery.AcknowledgmentsThe authors thank Mrs Petra Homoet-van der Kraak for her excellent technical support.DisclosuresNone.FootnotesCorrespondence to Aryan Vink, MD, PhD, University Medical Center Utrecht, Department of Pathology, Room H04–312, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail a.[email protected]nlReferences1. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H. Bypass versus angioplasty in severe ischaemia of the leg (basil): multicentre, randomised controlled trial. Lancet. 2005; 366: 1925– 1934. CrossrefMedlineGoogle Scholar2. Bolia A, Miles KA, Brennan J, Bell PR. Percutaneous transluminal angioplasty of occlusions of the femoral and popliteal arteries by subintimal dissection. Cardiovasc Intervent Radiol. 1990; 13: 357– 363. CrossrefMedlineGoogle Scholar3. Reekers JA, Kromhout JG, Jacobs MJ. Percutaneous intentional extraluminal recanalisation of the femoropopliteal artery. Eur J Vasc Surg. 1994; 8: 723– 728. CrossrefMedlineGoogle Scholar4. Ho GH, Moll FL. Remote endarterectomy in SFA occlusive disease. Eur J Radiol. 1998; 28: 205– 210. CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kuntz S, Lejay A and Chakfé N (2021) Subintimal Angioplasty in the Superficial Femoral Artery: A Real Long Term Option Demonstrated by Histology, EJVES Vascular Forum, 10.1016/j.ejvsvf.2021.08.003, 52, (49-50), . Babaev A, Hari P, Gokhale R and Zavlunova S (2017) A single-center retrospective analysis of patency rates of intraluminal versus subintimal endovascular revascularization of long femoropopliteal occlusions, Cardiovascular Revascularization Medicine, 10.1016/j.carrev.2017.03.016, 18:6, (399-404), Online publication date: 1-Sep-2017. Chakfé N (2017) Commentary on "A Pilot Study of Femoropopliteal Artery Revascularisation With a Low dose Paclitaxel Coated Balloon: Is Predilatation Necessary?", European Journal of Vascular and Endovascular Surgery, 10.1016/j.ejvs.2017.07.008, 54:3, (356), Online publication date: 1-Sep-2017. Akamatsu D, Fujishima F, Goto H, Hashimoto M, Tsuchida K, Kawamura K, Tajima Y, Umetsu M, Suzuki S and Kamei T (2017) Histological Analysis of a New Route after Subintimal Crural Angioplasty, Annals of Vascular Surgery, 10.1016/j.avsg.2017.06.038, 45, (262.e15-262.e19), Online publication date: 1-Nov-2017. Niazi K (2015) Focal Stenting Versus "Metal Jacket" for Long Subintimal Recanalization of the Femoropopliteal Artery, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2014.12.006, 8:3, (481-482), Online publication date: 1-Mar-2015. Davaine J, Quérat J, Guyomarch B, Costargent A, Chaillou P, Patra P and Gouëffic Y (2014) Primary Stenting of TASC C and D Femoropopliteal Lesions: Results of the STELLA Register at 30 Months, Annals of Vascular Surgery, 10.1016/j.avsg.2014.03.033, 28:7, (1686-1696), Online publication date: 1-Oct-2014. Spiliopoulos S, Theodosiadou V, Koukounas V, Katsanos K, Diamantopoulos A, Kitrou P, Ravazoula P, Siablis D and Karnabatidis D (2014) Distal Macro- and Microembolization During Subintimal Recanalization of Femoropopliteal Chronic Total Occlusions, Journal of Endovascular Therapy, 10.1583/14-4703.1, 21:4, (474-481), Online publication date: 1-Aug-2014. February 2012Vol 5, Issue 1 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.111.967026PMID: 22338007 Manuscript receivedNovember 23, 2011Manuscript acceptedDecember 29, 2011Originally publishedFebruary 1, 2012 Keywordshistologyrevascularizationperipheral vascular diseasesangioplastyPDF download Advertisement SubjectsCardiovascular SurgeryPercutaneous Coronary InterventionTreatment