Subintimal angioplasty as a primary modality in the management of critical limb ischemia: comparison to bypass grafting for aortoiliac and femoropopliteal occlusive disease.

Purpose: To compare the 30-day morbidity, mortality, length of hospital stay, and patency rates in patients with critically ischemic limbs treated with subintimal angioplasty (SA) versus standard bypass surgery.

Method: Between October 2001 and August 2003, 137 patients (74 women; mean age 70 years, range 43-92) with critical limb ischemia underwent subintimal angioplasty (n=88) or bypass surgery (n=49) for superficial femoral artery (SFA) or aortoiliac lesions. All patients had lesions classified as C or D according to the TransAtlantic Inter-Society Consensus. Data was retrieved from hospital inpatient inquiry and VascuBase. Parallel group comparison was used in performing a prospective observational study.

Results: Primary technical success was 100% for both SA and bypass grafting. Thirty-day survival was 100% in the SFA-SA and aortoiliac bypass groups and 96% and 93%, respectively, in the SFA bypass and aortoiliac SA groups. Limb salvage was 97% and 82% in the SFA-SA and SFA bypass groups, respectively; at the aortoiliac levels, the rates were 100% and 86% for SA versus bypass. Subintimal angioplasty significantly reduced hospital stay (p<0.001). Primary patency was not statistically different in the SA versus bypass groups; however, secondary patency was higher in the SFA bypass group.

Conclusions: Frequent clinical follow-up and a duplex surveillance program are necessary to maintain patency in this cohort. Subintimal angioplasty is increasingly replacing bypass surgery in the management of critical limb ischemia without compromising primary patency, limb salvage, patient survival, or subsequent vascular intervention.