Long-Term Outcomes in Subintimal Arterial Flossing with Antegrade–Retrograde Intervention (SAFARI)

Purpose: To our knowledge, this is the first study to evaluate patency and clinical outcomes beyond 3 years for SAFARI recanalization.

Materials and Methods: A single-center retrospective chart review of all SAFARI cases from 2012-2022 were reviewed. Patency was confirmed utilizing a combination of ultrasound duplex, CT, and angiographic findings. Longitudinal outcomes were quantified with Kaplan-Meier analysis. Patients who did not have follow up ≥ 3 years were excluded.

Results: A total of 55 limbs in 45 patients were included in our analysis (69% men; median age 65). Comorbidities included: HTN 98%, DM 84%, HLD 60%, smoking history 71%, CAD 67%, and CKD/ESRD 58%. Rutherford Classification (RC) distribution: 7% RC-3, 24% RC-4, 49% RC-5, and 20% RC-6.

The technical success rate for SAFARI was 100%. The median follow-up time was 51 months.



Primary patency rate at 6 months - 65% (95% CI: 51–76%), 12 months - 57% (95% CI: 43–69%), 24 months - 50% (95% CI: 36–62%), 36 months - 41% (95% CI: 28–53%), 48 & 60 months - 38% (95% CI: 25–51%), and 72, 84, & 96 months - 33% (95% CI: 19–48%).

Primary-assisted patency rate at 6 months - 72% (95% CI: 58–82%), 12 months - 67% (95% CI: 53–78%), 24 months - 61% (95% CI: 47–73%), 36 months - 57% (95% CI: 43–69%), 48 months - 55% (95% CI: 40–67%), and 60, 72, 84, & 96 months - 51% (95% CI: 36–64%).

The secondary patency rates at 6 months - 94% (95% CI: 84–98%), 12 & 24 months - 89% (95% CI: 77–95%), 36 months - 85% (95% CI: 73–92%), 48 & 60 months - 82% (95% CI: 69–91%), and 72, 84, & 96 months - 75% (95% CI: 53–88%).

AFS rates at 6, 12, 24, and 36 months - 98% (95% CI: 88–100%), 48 months - 95% (95% CI: 81–99%), and 60, 72, 84, & 96 months - 88% (95% CI: 70–96%).

Conclusion: We report remarkably high durability of SAFARI, with longitudinal follow-up and appropriate reintervention. In particular, we demonstrate a 5-year secondary patency rate of 82% for SAFARI. By comparison, for femoropopliteal bypass, 5-year secondary patency rates are slightly lower at 73.2%, 80.1%, and 79.7% for above-knee PTFE, above-knee GSV, and below-knee GSV conduits, respectively {1}. Conversely, 5-year primary patency rates for femoropopliteal bypass (57.4-77.2% depending on conduit) are superior to our reported SAFARI outcomes. Note that our sample size for SAFARI is smaller than referenced datasets for bypass. Clinical outcomes in SAFARI were also excellent, with AFS exceeding 88% at 3-8 year endpoints.

In conclusion, SAFARI is technically feasible, safe, and highly durable. We report long-term secondary patency rates comparable to GSV bypass, without the risk of perioperative complication or prolonged recovery associated with surgery.