title: Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia.
abstract: OBJECTIVE
  To describe the technique of subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) to improve technical success for the performance of subintimal recanalization when there is failure to reenter the distal true lumen or when there is a limited segment of patent distal target artery available for reentry.
  
  
  METHODS
  Subintimal recanalization was attempted in an antegrade direction in all patients. If reentry into the distal true lumen was unsuccessful or a short segment of target artery was present, retrograde access was obtained in the distal target artery (popliteal, anterior tibial/dorsalis pedis, or posterior tibial) and a retrograde subintimal channel was created. A guide wire was used to connect the retrograde and antegrade subintimal channels simultaneously to create a "flossing" guide wire. The subintimal tract was dilated with balloon angioplasty with or without stent implantation. Limb salvage, amputation-free survival, and survival rates over time were determined.
  
  
  RESULTS
  The SAFARI technique resulted in successful subintimal recanalization creating straight-line flow to the foot in all 21 limbs in 20 patients in which the technique was attempted. Antegrade-retrograde access was performed with the femoral artery and the following vessels: popliteal, n = 11; anterior tibial/dorsalis pedis, n = 10; and posterior tibial, n = 2 (two limbs involved multiple accesses). All procedures were successful. The limb salvage rate with SAFARI was 90% (95% CI, 74%-100%) at 6 months.
  
  
  CONCLUSIONS
  The SAFARI technique can be useful for completing subintimal recanalization when there is failure to reenter the distal true lumen from an antegrade approach or when there is limited distal target artery available for reentry. The SAFARI technique improves technical success in the performance of subintimal recanalization. Limb salvage rates are comparable to those with antegrade subintimal recanalization.
authors.affiliation: Fairfax Radiology Consultants, Inova Fairfax Hospital, Falls Church, Virginia, USA. djs4m@virginia.edu
authors.forename: David J
authors.initials: DJ
authors.lastname: Spinosa
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Harthun
authors.forename: Eric A
authors.initials: EA
authors.lastname: Bissonette
authors.forename: Dorothy
authors.initials: D
authors.lastname: Cage
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Leung
authors.forename: John F
authors.initials: JF
authors.lastname: Angle
authors.forename: Klaus D
authors.initials: KD
authors.lastname: Hagspiel
authors.forename: John A
authors.initials: JA
authors.lastname: Kern
authors.forename: Ivan
authors.initials: I
authors.lastname: Crosby
authors.forename: Harry A
authors.initials: HA
authors.lastname: Wellons
authors.forename: Gary D
authors.initials: GD
authors.lastname: Hartwell
authors.forename: Alan H
authors.initials: AH
authors.lastname: Matsumoto
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000628:therapy*; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007511:Ischemia / Q000628:therapy*; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011677:Punctures; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome; D017539:Tunica Intima