Angioplasty versus stenting for subclavian artery stenosis

Angioplasty versus stenting for subclavian artery stenosis

BACKGROUND

The subclavian arteries are two major arteries of the upper chest, below the collar bone, which come from the arch of the aorta. Endovascular treatment for stenosis of the subclavian arteries includes angioplasty alone, and with stenting. There is insufficient evidence to guide the use of stents following angioplasty for subclavian artery stenosis. This is the second update of a review first published in 2011.

OBJECTIVES

The aim of this review was to determine whether stenting was more effective than angioplasty alone for stenosis of the subclavian artery.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 February 2021.

SELECTION CRITERIA

We searched for randomised controlled trials of endovascular treatment of subclavian artery lesions that compared angioplasty alone and stent implantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, we asked a third review author to assess the study for inclusion. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions, and assess the certainty of the evidence using a GRADE approach.

MAIN RESULTS

To date, we have not identified any completed or ongoing randomised controlled trials that compare percutaneous transluminal angioplasty and stenting for subclavian artery stenosis.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

Treatment-Related Cardiovascular Outcomes in Patients with Symptomatic Subclavian Artery Stenosis

Background

Subclavian artery stenosis (SAS) is narrowing of the subclavian artery most commonly caused by atherosclerosis. It serves as a marker for cerebrovascular and myocardial ischemic events.

Methods

A retrospective cohort study was conducted to determine the association of treatment via combination therapy (antiplatelet drug plus either by-pass surgery or percutaneous transluminal angioplasty (PTA) with or without stent implantation) versus antiplatelet drug therapy alone on cardiovascular events and all-cause mortality in Marshfield Clinic patients diagnosed with symptomatic SAS from January 1, 1995 to December 31, 2009.

Results

Of the total 2153 cases, 100 patients were identified as eligible to be included in the study. Of these 100 patients that met inclusion criteria, 30 underwent combination therapy while 70 were managed only with drug treatment. A median length of follow-up was 8.45 years. Adverse cardiovascular events occurred in 5/30 (17%) of combination therapy patients compared to 28/70 (40%) of antiplatelet drug therapy only patients (p = 0.0355). Accordingly, all-cause mortality was higher (47%) in the antiplatelet drug therapy only group than the combination therapy group (13%) [hazard ratio = 3.45, p = 0.0218].

Conclusions

Preliminary findings in this pilot data set suggest that combination therapy (medications plus either surgical or interventional repair) of subclavian artery stenosis is associated with less cardiovascular adverse events and higher survival rates. However, prospective randomized studies with larger number of patients are needed to validate these findings.

Drug coated balloon angioplasty for subclavian artery stenosis: A potential novel indication

Subclavian artery stenosis is associated with increased cardiovascular disease mortality. It remains an important treatable cause of upper extremity, brain and cardiac ischemia. Endovascular treatment with angioplasty and stenting has become the preferred modality of treatment. Surgical revascularization is reserved for difficult cases with unfavorable anatomy to endovascular approach. Here we describe a case of subclavian artery stenosis causing subclavian steal syndrome with unfavorable anatomy to stenting treated successfully with drug coated balloon angioplasty with maintenance of patency at 6months.

Treatment of subclavian artery stenosis: A case series

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Case presentation of a patient treated with subclavian artery stenting.

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Case presentation of a patient treated with transposition of the left subclavian artery onto the left common carotid artery.

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Case presentation of a patient treated with carotid- subclavian artery bypass with a PTFE graft.

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Case presentation of a patient treated with carotid to axillary bypass.

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Discussion and literature review of methods and indications of treatment of subclavian artery occlusive disease.

Introduction

In this case series, different modalities of treatment for patients with ischaemic symptoms of subclavian stenosis are described, including the different operative strategies that can be adopted in more challenging cases. This is the first case series describing these four management options.

Presentation

Case 1: A seventy-one year-old female presented with acute on chronic ischaemia of her left arm following a fall and developed dry gangrene of her left thumb. This was initially managed with a heparin infusion followed by stenting of the subclavian artery which relieved her symptoms. Case 2: A fifty-nine year-old male presented with chronic ischemia of the left arm secondary to an occlusion of the left subclavian artery. This was managed by transposition of the left subclavian artery onto the left common carotid artery. Case 3: A sixty-four year-old female presented with left subclavian steal syndrome secondary to subclavian artery stenosis. She underwent carotid subclavian artery bypass. Case 4: A fifty-six year-old female presented with acute left upper limb ischaemia secondary to acutely thrombosed subclavian artery on a CT-angiography. She underwent a carotid to axillary bypass.

Discussion and conclusion

This case series demonstrates the treatment options available to vascular surgeons when managing symptomatic subclavian artery disease. Symptomatic subclavian artery occlusive disease should be treated with endovascular stenting and angioplasty as first line management. If it is not successful then open surgery should be considered. Bypassing the carotid to the subclavian or to the axillary artery are both good treatment modalities.