The impact of subintimal lesion crossing on femoro-popliteal endovascular treatment outcomes

INTRODUCTION: Subintimal angioplasty is an endovascular technique used to recanalize occluded segments in the arterial bed that cannot be crossed via an intraluminal path. However, there is still limited data regarding the clinical outcome of subintimal angioplasty. The aim of this study is to evaluate the impact of subintimal angioplasty in femoro-popliteal lesions. METHODS: This is a retrospective, single-centre, comparative study. From January 2023 to February 2025, all patients with chronic lower limb ischemia due to femoro-popliteal arterial lesions who underwent endovascular treatment as a first revascularisation procedure were considered. Patients were grouped according to the cross-lesion pathway: the subintimal cross-lesion group (S group) and the intraluminal cross-lesion group (L group). Both groups were compared with respect to the atherosclerotic disease pattern, and the primary endpoints were the rates of reintervention and amputation. RESULTS: The study included 95 patients, of whom 10% (n = 9) presented with intermittent claudication and 90% (n = 85) with chronic limb-threatening ischaemia. The median follow-up time was nine months. The S group included 30% (n = 28) of the patients and L group included 70% (n = 67). The median femoro-popliteal GLASS classification was 4 in both groups, but this GLASS stage was more common in S group (p = 0.004). Severe calcification (p < 0.001) and bailout stenting (p < 0.001) were more common in the S group. Regarding the primary endpoints, no statistically significant differences were found between groups in rates of reintervention (p = 0.95) and amputation (p = 0.26) at 12 months of follow-up. CONCLUSION: Our results suggest that the clinical outcomes of subintimal angioplasty are similar to those of intraluminal angioplasty, with comparable limb outcomes in patients with femoro-popliteal lesions. These findings may support adopting a lower threshold for subintimal crossing in calcified and complex lesions, as it can achieve good results with comparable outcomes to the intraluminal angioplasty.