In this episode, host Dr. Ally Baheti interviews interventional radiologist Dr. Luke Wilkins about his approach to the subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique for crossing challenging chronic total occlusions (CTO) in critical limb ischemia (CLI) patients.

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SHOW NOTES

Dr. WIlkins gives us the basic indication for the procedure, which is when the lesion is unable to be crossed from a purely antegrade approach and other re-entry devices have failed. Dr. Wilkins will always attempt to use an Outback wire and an Enteer balloon before performing the SAFARI technique. There are multiple factors that influence the decision to use SAFARI, such as lesion location, level of calcification, and size of the true lumen at the re-entry point.

Next, Dr. Wilkins walks us through a typical SAFARI. He normally establishes retrograde access in the dorsalis pedis or posterior tibial artery using a 4 cm micropuncture needle and an exchange length Nitrex wire. He uses telescoping catheters from the antegrade direction. When the antegrade and retrograde approaches enter the same subintimal plane, the 2 devices can connect and the lesion can be crossed. If it is challenging to achieve the same intimal plane for both devices, the gunsight approach of overlapping snares can be utilized. After the lesion is crossed, normal angioplasty and stenting can occur.

Dr. Wilkins gives advice on how to make the procedure efficient. In occlusions that are longer than 1 cm, he always makes sure that the foot is prepped before the case starts. He also emphasizes the importance of knowing when to try a different technique and notes that this intuition comes from experience.

Finally, we discuss patency rates for SAFARI patients, which have been relatively high. This technique has made a large impact on limb salvage in a patient population that previously had no other non-surgical options.

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RESOURCES

Rotarex Atherectomy System:
https://www.bd.com/en-us/products-and-solutions/products/product-families/rotarex-rotational-excisional-atherectomy-system

Outback Re-Entry Catheter:
https://cordis.com/na/products/cross/endovascular/outback-elite-re-entry-catheter

Enteer Re-Entry Catheter/Balloon:
https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/chronic-total-occlusion-devices/enteer/indications-safety-warnings.html

Nitrex Wire:
https://www.medtronic.com/us-en/healthcare-professionals/products/cardiovascular/guidewires/nitrex.html

CXI Catheter:
https://www.cookmedical.com/products/di_cxi_webds/

Outcome and Distal Access Patency in Subintimal Arterial Flossing with Antegrade-Retrograde Intervention for Chronic Total Occlusions in Lower Extremity Critical Limb Ischemia:
https://www.jvir.org/article/S1051-0443(19)31033-4/fulltext