Subintimal Versus Intraluminal Approach for Femoropopliteal Chronic Total Occlusions Treated With Intravascular Ultrasound Guidance

BACKGROUND: The subintimal approach (SA) is widely used in endovascular therapy for femoropopliteal chronic total occlusion lesions. However, when compared with the intraluminal approach (IA), the safety and efficacy of SA in real‐world practice are not well characterized. Furthermore, there is a paucity of data on the clinical impact of subintimal and intraluminal wire passage (SWP and IWP, respectively) assessed by intravascular ultrasound. METHODS AND RESULTS: From the IVORY (Intravascular Ultrasound‐Supported Endovascular Therapy in Superficial Femoral Artery) registry, this study included 500 patients undergoing endovascular therapy for femoropopliteal chronic total occlusion lesions (SA, n=67; IA, n=433; and SWP, n=186; IWP, n=314). The primary end point was the cumulative 1‐year incidence of restenosis. The rate of perioperative complications was also assessed. Propensity score matching analysis was performed to adjust for the intergroup differences. After propensity score matching, the final study population consisted of 59 pairs (SA, n=59; IA, n=348) and 170 pairs (SWP, n=170; IWP, n=293), respectively. Cumulative 1‐year incidence of restenosis was comparable between the SA and IA groups (41.0% versus 43.4%, P=0.40). No significant difference in 1‐year restenosis rate between the SWP and IWP groups was observed (48.2% versus 40.8%, P=0.40), although the SWP group tended to be a higher rate of perioperative complications than the IWP group (8.2% versus 4.1%, P=0.07). CONCLUSIONS: At 1 year, both SA and IA showed acceptable results for femoropopliteal chronic total occlusion lesions. Cumulative 1‐year incidence of restenosis was not significantly different between SWP and IWP, whereas perioperative complications occurred more frequently in SWP than in IWP. REGISTRATION: URL: https://www.umin.ac.jp; Unique identifier: UMIN000020472.