Original title: Subintimal Recanalization Plus Stenting or Bypass for Management of Claudicants with Femoro-popliteal Occlusions. Reference: Boufi et al. Eur J Vasc Endovasc Surg. Volume 46 Issue 3 September/2013.

The main criticism of sub intimal technique is its relative low permeability compared to the surgical technique . Different studies reported a permeability between 56 and 70 % annually .

In patients with critical ischemia , this relatively high rate of re occlusion does not affect the clinical objective of the affected limb recover . However, in patients with claudication success depends on the relief of symptoms ( directly related to permeability ) and not just to avoid amputation.

Between 2004 and 2011 all patients  treated in a center,  were reviewed retrospectively with claudication and occlusion of the superficial femoral artery. The technique to use ( sub intimal recanalization or femoropopliteal bypass ) was at the discretion of the surgeon, occlusion of the middle segment / distal were  treated generally by endovascular technique, more complex occlusions were treated by surgery . No reentry devices  for sub intimal were used as were not available at the center during the study period. A systematic clinical follow up and Doppler at 1, 3 , 6 and 12 months was performed after that every year. Restenosis was defined as ≥ 50% injury or a relationship between the speed in the common femoral and popliteal,  greater than 3. A total of 82 consecutively treated patients with femoropopliteal bypass and 58  with stent sub intimal angioplasty. The patients showed normal comorbidities typical in these patients with a 45.2 % of diabetics. In the endovascular group technical success was 93 % and 100% in the surgical .

In the mean follow-up for 36 months , the primary patency of angioplasty was 64.6 % and secondary patency of 90.1 % compared to 58.5 % and 84 % respectively of femoropopliteal bypass. 

Conclusion:

This study provides additional evidence to sub- intimal angioplasty with stent implantation in patients with intermittent claudication and long occlusions of the superficial femoral artery. The surgery or endovascular indication can be seen by the shape of the occlusion and these techniques, far from competing , can be complementary. 

Editorial Comment:

The rationale behind the endovascular strategy is to offer a less invasive treatment preserving the saphenous vein and avoiding or at least delaying the need for surgery . Failing to recanalization or reocclusion at follow-up does not preclude subsequent successful surgery . The use of specific reentry sub intimal devices (not used in this work ) improves technical success mainly in longer and calcified occlusions.

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