Initial and 3-year results after subintimal versus intraluminal approach for long femoropopliteal occlusion treated with a self-expandable nitinol stent

Background: Intraluminal femoropopliteal stenting enables favorable dilation and good immediate results; however, whether this contributes to long-term patency is unclear. We compared patency after femoropopliteal stenting for a long occlusion using either an intraluminal or subintimal approach. Methods: Between January 2004 and December 2011, 902 endovascular procedures using either an intraluminal approach (651 procedures) or a subintimal approach (251 procedures) for long femoropopliteal occlusion were analyzed retrospectively. The outcomes of this study were periprocedural complication; primary, assisted-primary, and secondary patency; and overall survival. Results: The mean follow-up period of survivors was 29 6 16 months. Between the intraluminal and subintimal approach, technical success (91% vs 90%; P = .71) and periprocedural complications (11% vs 13%; P = .34) were similar. However, procedure time was significantly longer for the intraluminal approach (126 +/- 63 minutes vs 98 +/- 49 minutes; P = .003). The improvement of ankle-brachial index was also similar. A quarter of cases started with the intraluminal approach were switched to a subintimal approach. There was no significant difference in primary, assisted-primary and secondary patency at 3 years between the two groups (55% vs 53%; P = .30; 65% vs 74%; P = .11; and 80% vs 85%; P = .37). The 3-year overall survival also did not differ significantly between groups (84% vs 86%; P = .55). After adjusting for baseline differences, the subintimal approach was found to be similar to the intraluminal approach for primary patency (hazard ratio, 1.21; 95% confidence interval, 0.94-1.56; adjusted P = .14). Conclusions: Initial result and 3-year patency was similar in both approaches. Given the longer procedure time and high crossover rate, we suggest that a subintimal approach may be preferred in the treatment of long femoropopliteal occlusions with stenting.