Peripheral transluminal angioplasty of the subclavian and innominate arteries utilizing the brachial approach: acute outcome and follow-up

Subclavian angioplasty: immediate and late results in 50 patients

In order to assess the therapeutic outcome of percutaneous transluminal angioplasty for subclavian stenosis, 50 patients were followed up clinically as well as with a velocimetric Doppler after attempted angioplasty. A minimal clinical follow-up of 9 months was expected. Subclavian stenoses were due to atheroma in 49 patients and to Takayasu's disease in 1 case. Indication of angioplasty was curative in 34 (68%) symptomatic patients (posterior fossa ischemia and/or upper limb ischemia) and preventive in 16 (32%) asymptomatic patients (severe difference of blood pressure between the 2 arms and/or association with carotid stenosis or axillo-femoral bypass). Angioplasty was successful in 45 patients (primary success rate = 90%). Three (6%) thrombosis occurred due to the percutaneous approach, one of the axillary and one of the brachial artery without any significant sequelae, and one of the aorta requiring an aorto-bifemoral bypass. A complication occurred in 2 unsuccessful angioplasties (4%): an ischemic stroke occurred in 1 case and a thrombosis of the dilated site requiring a surgical bypass. Clinical follow-up over a period of 9-101 months (mean = 41) was performed in 43 out of the 45 patients who had undergone angioplasty successfully. Two patients had a follow-up shorter than 9 months: one died after 5 months, the other was lost to follow-up. By the end of the clinical follow-up, 37 (84%) out of the 44 followed-up patients had benefitted from the procedure. Doppler study performed in 35 out of the 44 followed-up patients (80%) over a period of 2-90 months (mean = 39) showed 5 restenosis (14%). This study demonstrates the good long-term results of angioplasty in case of subclavian artery stenosis. Though there are complications, angioplasty could be proposed as a first choice treatment for subclavian stenosis as compared to surgery. Indications in asymptomatic patients should be carefully weighed as complications may occur.

Options for percutaneous coronary and peripheral revascularization

Angioplasty has become an established treatment for both coronary and peripheral atherosclerosis, and a number of new techniques and devices promise to improve the results of percutaneous intervention during the coming decades. It is likely that balloon angioplasty will remain the percutaneous treatment of choice for both coronary and peripheral intervention; however, we look with hope toward the development of new devices that will expand the role of percutaneous angioplasty and improve the long-term success of these procedures. As technical expertise grows with the new procedures, prospective randomized trials comparing them with standard PTCA will be required to enable physicians to judge their clinical utility.

Percutaneous transluminal angioplasty for occlusion of the subclavian artery: short- and long-term results

Percutaneous transluminal angioplasty was performed in 8 symptomatic patients with proximal occlusion of the left subclavian artery. Technical and short-term clinical success was achieved in 7 cases. Nonoccluding embolization to the distal subclavian artery and stenosis of the brachial artery after a combined femoral/brachial approach occurred as complications in 2 patients. Three patients are asymptomatic with a patent subclavian artery 25, 28, and 37 months after angioplasty. Reobstructions in 4 patients occurring after 8, 12, and 16 months were retreated by angioplasty (3 patients) and stent implantation (1 patient with a second restenosis) with good technical and clinical success. Long-term patency was less than 50%, but successful retreatment is feasible. Therefore, we consider percutaneous transluminal angioplasty a reasonable therapeutic option in patients who are not surgical candidates.

Subclavian artery angioplasty for treatment of coronary artery steal syndrome

Three patients underwent percutaneous transluminal angioplasty for treatment of subclavian artery stenosis producing the coronary artery steal syndrome. Technical success and immediate relief of angina were achieved in all three patients. Clinical follow-up ranged from 4 to 16 months. One patient developed clinical evidence of restenosis. Subclavian artery angioplasty may be a safe and efficacious technique for the treatment of the coronary artery steal syndrome.

Subclavian balloon angioplasty in the management of the coronary-subclavian steal syndrome

The syndrome of coronary-subclavian steal presenting with angina pectoris after coronary revascularization with the mammary arteries is not common. This disorder should be suspected in post LIMA patients with blood pressure differences between the arms and confirmed by angiography. PTA of the subclavian artery via the brachial approach, in appropriately selected patients, offers potential advantages over carotid subclavian bypass including an apparent lower complication rate with equally good results. Recurrences, which are apt to be more common after PTA versus carotid subclavian bypass, are easily managed with repeat dilatation. This course of management in our patient resulted in an excellent clinical outcome without complication. This report emphasizes the importance of considering subclavian stenosis in patients with prior LIMA bypass grafting, particularly when the ipsilateral arm blood pressure is reduced. In such cases, subclavian PTA offers a reasonable nonsurgical approach for correction.