Videos | Subintimal angioplasty | Which Medical Device

This short video illustrates the technique of subintimal angioplasty using a 4F angioplasty balloon and 018 guidewire (Biotronik Passeo 018).

Normally I would start with an 035" guidewire for access, 4F sheath insertion and catheter insertion. The catheter is placed up against the edge of the occlusion/plaque. I then insert an 035" curved hydrophilic guidewire and start dissecting in the subintimal plane by pushing a loop of wire forward ahead of the catheter. The catheter and wire are then advanced together in the subintimal plane through the occlusion.

When relatively normal vessel is encountered the loop of wire is shortened and hopefully will pop back into the true lumen. Its usually obvious when the wire is back in the vessel as it will rotate freely. Its best to check this with a small injection of contrast prior to angioplasty. The 035 wire is then exchanged for an 018 wire over which to insert the 4F balloon. I usually perform angioplasty using a roadmap which demonstrates the exact site of the occlusion and also confirms correct balloon sizing. Once the occlusion is crossed with the wire I inject 2500iu of heparin prior to angioplasty.

Angioplasty often has to be performed using a pressure inflation device starting from the most distal lesion moving proximally. Once flow is restored I usually finish the procedure. Second angioplasty for a smooth 'perfect' result can sometimes lead to distal embolization. The vessel will remodel and I think flow is more important than the actual radiological appearance.

Stenting can also be considered if flow is not good.

Dr Phil Haslam
Consultant Interventional Radiologist, Freeman Hospital, Newcastle, UK