Angioplasty First Approach to Critical Limb Ischaemia (CLI): Our Experience with SAFARI (subintimal Arterial Flossing with Antegrade-Retrograde Intervention) Technique for Infra-Inguinal Arterial Occlusions

Review of angioplasty first approach to challenging infrainguinal occlusions using SAFARI technique. We have adopted an angioplasty first approach to critical limb ischemia in 2007. Infrainguinal, especially infrapopliteal intervention forms a large part of our CLI practice and most of these patients are diabetic. Chronic long segment calcified total occlusions of SFA and below knee vessels are not uncommon and are most challenging to manage endovascularly. In 2009 we started performing SAFARI technique for those lesions that failed antegrade recanalization and here, we review our experience with this approach. Data was collected from the Interventional Radiology section of our institute in Singapore. Between January 2009 to March 2013, 131 SAFARI procedures were performed in 117 patients (mean age: 70.7 years, range: 36 to 98 years, M:F 1:1) due to failure to cross lower extremity CTOs antegradely. All cases presented with critical limb ischemia (Fontaine III: 18, IV: 113). Proximal access was ipsilateral and contralateral common femoral artery in 109 and 22 procedures respectively. Distal retrograde access was obtained from the following arteries: popliteal (n=39), dorsalis pedis (n=28), anterior tibial (n=32), posterior tibial (n=21), peroneal (n=7), superficial femoral (n=3) and lateral plantar (n=1). Balloon assisted hemostasis was performed for distal retrograde punctures sites in 81 procedures. Mean follow up period was 5.4months (range 0.5 to 24.0 months). Very long segment (> 20cm) occlusions were seen in 51.9% of cases. Technical success was achieved in 107/131 (81.7 %) of procedures. A total of 156 limb segments were successfully recanalized with 63.4% limb salvage at 6 months. Causes of failure were inability to cross hard calcified plaques (8.3%), inability to reenter the true lumen after subintimal access (3.8%) and on-table reocclusion due to elastic recoil (2.2%). Major and minor complications were seen in 4 (3.1%) and 12 (9.1%) procedures respectively. There was no procedure related mortality. SAFARI technique in CLI is a safe and effective treatment option for difficult infra-inguinal lesions.