Novel Use of Subintimal Arterial Flossing With Antegrade–Retrograde Intervention for Chronic Upper Extremity Ischemia

Purpose: This case report describes use of the SAFARI technique for the treatment of chronic hand ischemia. To our knowledge, this report represents the first in the literature that describes the technique, and we believe that this may be a successful and safe approach for treatment of chronic below-the-elbow arterial occlusions.

Materials and Methods: Subintimal recanalization is used to treat arterial occlusion, predominantly in the lower extremity. Traditionally, an antegrade approach to the peripheral vasculature has resulted in high limb salvage rates. Although chronic hand ischemia is rare, reports have demonstrated the success and durability of above-the- elbow interventions for ischemia, though there are limited data on interventions for chronic critical hand ischemia secondary to below-the-elbow atherosclerotic occlusive disease.

Results: A 58-year-old woman with a history of peripheral vascular disease, end stage renal disease, and pulmonary hypertension presented to the interventional radiology department for left upper extremity angiogram. The patient was receiving hemodialysis via a right femoral graft because of thrombosis of her left upper extremity arteriovenous fistula. The patient complained of left upper extremity pain, weakness, and digital ulcers. Angiography revealed distal occlusion of the radial and ulnar arteries. The interosseous artery was identified as the dominant supply to the wrist and opacified the deep arch through collaterals. A 0.035 CXI catheter (Cook Medical) and Glidewire (Terumo Medical) combination was then advanced to the level of the distal radial artery at the level of occlusion in the wrist. A 0.014 CXI catheter was then introduced with the use of a PT Graphix wire (Boston Scientific) and successfully advanced across the occlusion. Over this, a 1.5-mm Å~ 2-cm balloon was used to angioplasty the occlusive segment. The wire was then advanced into the deep arch. The entire length of the radial artery to the level of the arch was angioplastied, and repeat angiogram demonstrated no residual stenosis with patency of the distal radial artery. There was evidence of improved flow to the digital arteries, as well as preferential flow through the radial artery over the interosseous artery.

Conclusions: This case study demonstrates feasibility of the SAFARI technique in critical limb ischemia of the upper extremity