Dr. Megaly Publishes Novel CLASH Technique for Complex Iliac Artery Occlusion in JACC: Cardiovascular Interventions

When standard approaches fail in complex peripheral artery disease, the difference between a salvaged limb and an amputation often comes down to whether a physician has the advanced techniques and the judgment to adapt in real time

Peripheral artery disease affecting the iliac arteries presents unique anatomical challenges, particularly when complete occlusion occurs alongside severe calcification in adjacent vessels. In a subset of these cases, wiring attempts create an aortic subintimal hematoma, a blood collection beneath the inner lining of the aorta, that forms a flap blocking further access to the true aortic lumen. Once this occurs, standard approaches become ineffective, and the intervention must either be abandoned or require a novel solution.

Dr. Megaly and colleagues published a technique addressing exactly this scenario in JACC: Cardiovascular Interventions. The paper describes the CLASH technique — Controlled Laceration of Aortic Subintimal Hematoma/Flap — developed to treat a patient with a non-healing leg wound and bilateral iliac artery disease who could not be treated by conventional means.

After an initial procedure was aborted to allow healing, and a second attempt four weeks later again failed due to a persistent aortic flap, Dr. Megaly's team deployed a targeted solution: using radial artery access to wire into the true lumen of the right common iliac artery, then advancing a large snare from the opposite femoral access to capture the wire and create a controlled laceration of the hematoma. This provided access to the true aortic lumen, allowing both iliac arteries to be stented with covered stents in a kissing configuration, restoring blood flow and achieving an excellent final result.

The technique was adapted from the SLASH approach (snare-assisted laceration of subintimal hematoma), originally described for chronic total occlusion interventions in the coronary artery, and represents its first application to aortic and iliac disease.

For patients with non-healing wounds or critical limb ischemia caused by blocked iliac arteries, this type of anatomical complexity can be the barrier between a successful revascularization and a failed procedure. Having access to a physician experienced in recognizing these scenarios and applying advanced, evolving techniques is directly relevant to whether blood flow is restored and tissue survives.

Dr. Michael Megaly specializes in complex and high-risk coronary interventions, chronic total occlusion (CTO) PCI, surgical turn-downs, complex peripheral artery disease, and limb salvage at Integris Health Heart Hospital in Oklahoma City.