Subclavian artery stenting: factors influencing long-term outcome

Long-term outcomes of endovascular therapy for right subclavian artery occlusive lesions: A multi-center experience

OBJECTIVE

To review our multi-institutional experience with endovascular therapy for right subclavian artery occlusive disease and to evaluate the long-term outcomes.

METHODS

We retrospectively evaluated all patients with right subclavian artery stenosis and occlusive disease who underwent endovascular therapy between March 2014 and September 2022 at two institutions. Patient baseline demographics, lesion characteristics, treatment strategies, and in-hospital and follow-up outcomes were prospectively collected and retrospectively analyzed.

RESULTS

Between March 2014 and September 2022, 73 patients underwent endovascular treatment at the two institutions. The dominant cause of lesions in this cohort was atherosclerosis. Three different types of lesions were summarized, and the corresponding endovascular strategies were performed. 66 patients (90.4%) underwent successful endovascular treatment, and 62 patients (84.9%) underwent balloon-expandable stent deployment. The mean perioperative in-hospital stay was 4.0 days (range, 3-6 days). Two patients died due to myocardial infarction, and one died of cerebral hemorrhage resulting from a traffic accident within 30 days of the intervention. The median follow-up time was 31.6 months (range, 12-96 months). No complications, including death, stroke, stent fractures, or migration, were noted in any patient during the follow-up period. The overall complication rate was 7/73 (9.6%), and 5/7 (6.9%) of the complications required reintervention.

CONCLUSIONS

Endovascular treatment of right subclavian artery lesions is safe, effective, and technically achievable. The reasonable use of balloon-expandable stents can achieve satisfactory outcomes with accurate orientation and promising patency.

Endovascular Treatment for Subclavian Artery Stenosis and Occlusion: A Single-Center Retrospective Study

BACKGROUND

Subclavian artery stenosis and occlusion are common arterial diseases in the upper extremities, with atherosclerosis being the main cause. Endovascular treatment has emerged as a promising alternative to open surgical repair, but data are limited. This study aimed to evaluate the safety and effectiveness of endovascular procedures in the treatment of subclavian artery lesions at a tertiary vascular center in Vietnam.

METHODS

A retrospective analysis was conducted on patients who underwent endovascular treatment for symptomatic subclavian artery stenosis or occlusion between October 2013 and April 2022. Clinical characteristics, procedural details, short- and long-term outcomes, and patency rates were assessed.

RESULTS

Twenty-five patients were included in the study, with a mean age of 56.8 years. The majority of patients had risk factors for atherosclerosis, and all presented with symptoms related to subclavian artery disease. The endovascular procedures were successful in 96% of cases, with a low complication rate of 8%. During a median follow-up of 43 months, the overall patency rate was 92% at three years.

CONCLUSION

Endovascular treatment of subclavian artery stenosis and occlusion is a safe and effective option, with excellent long-term patency rates. These findings support the use of percutaneous revascularization as the first-line therapy, particularly in experienced centers. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.

[Treatment of atherosclerotic lesion of the first segment of subclavian artery]

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Critical Analysis of Vertebral Artery Flow Patterns/Subclavian Steal Detected by Cerebrovascular Duplex Ultrasound Exams and Its Clinical Implications

BACKGROUND

The prevalence of subclavian steal (defined as retrograde/bidirectional vertebral artery flow) in the general population and in patients undergoing cerebrovascular duplex ultrasound (CDUS) exams is variable. This is the largest study to date to analyze the incidence of duplex-suggested subclavian steal in 5615 CDUS exams over a one year period and to examine its clinical implications.

PATIENT POPULATION AND METHODS

All consecutive CDUS exams performed over a one year period were examined for the presence of subclavian steal. Indications of testing, presence of posterior cerebral circulation/subclavian steal symptoms, and any interventions for subclavian steal were analyzed.

RESULTS

171/5,615 (3.1%) were found to have subclavian steal (duplex-suggested). 117 (2.1%) had retrograde flow and 54 (1%) had bidirectional flow. 104/171 (60.8%) were left sided. Indications for CDUS were: post CEA/CAS surveillance in 39 patients (22.8%), surveillance for progression of carotid stenosis in 76 patients (44.4%), TIA/stroke in 26 patients (15%), asymptomatic screening/carotid bruit in 18 patients (10.5%) and isolated posterior cerebral circulation symptoms in 12 patients (7%). 63% of patients had associated >50% carotid stenosis. The mean arm Doppler pressure gradient was 32.2 mmHg for asymptomatic patients vs 37mmHg for patients with posterior circulation symptoms (p=.3254). There were significant differences between the mean systolic arm pressure for patients with retrograde vs antegrade vs bidirectional flow (105 mmHg vs 146 vs 134, p<.0001). All patients with retrograde flow had >50% subclavian stenosis or occlusion (100/117 had subtotal/total occlusion) except for one patient. Meanwhile, 52/54 patients with bidirectional flow had >50% subclavian stenosis (6/54 with subtotal/total occlusion) while two patients were normal/<50% stenosis (p<.0001). Overall, 26/171 patients (15.2%) had interventions for disabling symptoms. 11/26 of all interventions were for disabling arm claudication, and only 10/171 patients (5.8%) were done for disabling posterior circulation symptoms with complete resolution of symptoms in all except one. At a late follow-up with a mean of 18 mos. (range 1-37 mos.), there was no late major stroke with only two lacunar infarcts (not subclavian steal related). There were also seven late deaths, none stroke related.

CONCLUSIONS

The incidence of subclavian steal in patients who undergo CDUS is relatively rare. Most of these patients are asymptomatic and can be treated conservatively with only a few percentage who may need intervention for disabling symptoms with good symptom resolution.

Subclavian Artery Stenting Under Cerebral Protection by Balloon-Guiding Catheter Inflation Inside the Aortic Arch at the Left Subclavian Artery Origin

BACKGROUND

We describe a simple and novel technique for cerebral protection during left subclavian artery (SA) stenting by inflation of a balloon-guiding catheter inside the aortic arch at the SA origin.

METHODS

A total of 12 patients with left SA stenosis underwent SA stenting with inflation of a balloon-guiding catheter inside the aortic arch at the left SA origin between January 2020 and December 2020. The SA stenting procedures under proximal protection were retrospectively reviewed to assess ischemic complications, hyperintense spots on diffusion-weighted imaging (DWI), and flow direction of left vertebral artery (VA) during balloon-guiding catheter inflation using ultrasonography (US).

RESULTS

The success rate of the SA stenting procedure was 100% with no symptomatic ischemic complications. None of the 12 patients showed small hyperintense spots in DWI. In all patients, the left VA on US during balloon inflation showed retrograde blood flow.

CONCLUSIONS

The left VA on US had retrograde blood flow during inflation of the balloon-guiding catheter inside the aortic arch at the SA origin. Therefore, the proximal balloon protection inside the aortic arch at the SA origin is a simple and maybe a safe technique for cerebral protection during SA stenting.

Multimodality imaging in subclavian steal syndrome

Subclavian steal syndrome is a rare vascular cause of recurrent effort-related syncope events, affecting ~2% of the general population. Here, we report a case of a 64-year-old male who was hospitalized because of recurrent effort-related syncope events. Physical examination revealed several characteristic clinical clues for subclavian steal syndrome. Indeed, through the use of multimodality imaging, the diagnosis was established. We demonstrate that the combination of history taking, thorough physical exam and subsequent imaging studies can establish a relatively rare diagnosis of recurrent syncope.

Angioplasty and stenting for symptomatic stenosis of the left subclavian artery complicated with aortic dissection

BACKGROUND

Aortic dissection is a rare but severe complication of percutaneous transluminal angioplasty and stenting (PTAS) for stenosis of the subclavian artery (SA). This retrospective study was designed to evaluate the risk factors and outcomes of patients with severe stenosis of the SA who underwent PTAS complicated by aortic dissection.

METHODS

Between 1999 and 2018, 169 cases of severe symptomatic stenosis of the SA underwent PTAS at our institute. Of them, six cases complicated by aortic dissection were included in this study. We evaluated the demographic features, technical factors of PTAS, and clinical outcomes in these six patients.

RESULTS

Aortic dissection occurred in 5.3% (6/113) of all left SA stenting cases but in none of the right SA stenting cases. All patients had hypertension and a high severity of SA stenosis (85.0 ± 13.0%, 60%-95%). Five of the six patients received balloon-expandable stents (83.3%). All patients had spontaneous resolution of the aortic dissection with conservative treatment. In a 63.33 ± 33.07 (7-118) month follow-up, five of the six patients (83.3%) had long-term symptom relief and stent patency.

CONCLUSION

Aortic dissection occurred in patients who underwent PTAS for severe stenosis of the left SA, mainly with balloon-expandable stents. We suggest using self-expandable stents and angioplasty with an undersized balloon during PTAS for severe stenosis of the left proximal SA to prevent aortic dissection.

Coronary Artery Bypass: Review of Surgical Techniques and Impact on Long-Term Revascularization Outcomes

Coronary revascularization for multivessel disease remains a common and costly source of hospitalizations in the United States. Surgical techniques influence outcomes for coronary bypass and also affect the need for percutaneous coronary intervention in the future. As more radial access has been used for coronary angiography, consideration for use of the radial artery as a surgical conduit remains unclear. Saphenous vein grafts are commonly used for coronary bypass, however long-term patency remains suboptimal, and is also associated with a higher risk of adverse events with percutaneous coronary intervention. Thus, understanding the interplay between coronary bypass techniques and percutaneous coronary intervention has become increasingly important.

Endovascular Therapy for the Steal Phenomenon due to the Innominate Artery Severe Stenosis and Bilateral Internal Carotid Artery Severe Stenosis

BACKGROUND

Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery.

CASE REPORT

A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively.

DISCUSSION

For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery.

CONCLUSIONS

Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial 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.

Subclavian Artery Disease: Diagnosis and Therapy

The diagnosis of brachiocephalic disease is often overlooked. Symptoms include arm claudication and vertebrobasilar insufficiency. In patients who have had the use of the internal mammary artery for coronary bypass surgery, the development of symptoms of myocardial ischemia should alert the clinician to the possibility of subclavian artery stenosis. Also, in patients who have had axillofemoral bypass, lower-extremity claudication may occur. Recognition involves physical examination and accurate noninvasive testing. Endovascular therapy has proven to be effective in alleviating symptoms in properly selected patients.

Endovascular treatment and morphology typing of chronic ostial occlusion of the subclavian artery

Chronic obstructive lesions of the subclavian artery (SCA) often result in subclavian steal syndrome, which leads to arm claudication, transient cerebral ischemia, and other serious complications. The lesions are classified as stenosis and occlusion, according to the degree of obstruction. Unlike totally occlusive lesions, including ostial occlusions, stenotic lesions have an excellent technical success rate. In the present study, ostial occlusions were classified into 4 types according to their angiographic appearance. A total of 8 patients (6 male, 2 female) with SCA occlusions were treated with percutaneous transluminal angioplasty and stenting over a 4-year period. Mean patient age was 65.6 years (range, 60-72 years). In total, 9 self-expanding and 1 balloon-expandable stent were implanted at the ostia of the SCA in 7 of the patients. One female patient did not undergo stenting. Bleeding at the access site was noted in 2 patients and was controlled by gauze pressure. The patient that did not undergo stenting was lost to follow-up with symptoms of a transient ischemic attack at 3 months. The mean follow-up time for the remaining 7 patients was 15.7 months (range, 1-36 months). No ischemic symptoms, neointimal hyperplasia, or restenosis was observed in these patients. The transfemoral artery operation approach is preferred for rat-tail and peak type occlusions, whereas the dual approach involving both femoral and radial arteries is preferred for hilly and plain type occlusions. The angiographic morphology typing used in the present study may serve as a reference to decide upon the interventional operation strategy to be used for improving the technical success rate.

Transposition of Subclavian Artery - Is It the Appropriate Choice?

INTRODUCTION

To present patients with symptomatic subclavian artery disease and treatment possibility.

CASE REPORT

A 53-year-old female was admitted with vertigo and left arm claudication. Duplex-scan and MSCT arteriography verified subclavian artery occlusion. After the endovascular treatment failure, the patient was switched to surgical treatment - subclavian artery transposition. After the successful surgical treatment, the patient was discharged on the second postoperative day. If the patient is a candidate for surgery, the literature review shows good initial and long-term results after the subclavian artery transposition, and emphasizes this technique as superior.

CONCLUSION

Subclavian carotid transposition is a safe and effective method of treatment in patients after endovascular treatment failure or other indication. Also, the surgical treatment is technically demanding because of the difficult access to the vessel origin, and it requires experienced surgeons.

Endovascular Treatment of the Subclavian Artery Steno-Occlusive Disease

OBJECTIVE

The aim of our study was to compare immediate and long-term results of endovascular interventions for the treatment of steno-occlusive disease of subclavian arteries (SAs) depending on the length of lesion.

MATERIALS AND METHODS

Between 2010 and 2013, we performed 245 endovascular procedures to treat patients with atherosclerotic steno-occlusive disease of SAs. All patients were examined and subdivided according to the received results into 2 groups: 125 patients with stenosis of SA were included in the first group and 120 patients with occlusion of SA were included in the second group. The patients were then followed up at 6, 12, 24, 36, and 48 months after endovascular interventions. Follow-up visits contained symptomatic evaluation, clinical assessment with physical examination, complete neurological evaluation, and serial color Doppler ultrasonography.

RESULT

Transitory ischemic attacks in the vertebrobasilar system were intraoperatively developed by 1 patient from the first group (.8%) and 3 patients from the second group (2.5%). Reinterventions in the long-term period were carried out in 9 (7.2%) cases in the first group and 12 (10%) cases in the second group (P = .43). The cumulative primary stent patency at 4 years was 89.8% in the first group and 87% in the second group (P = .4).

CONCLUSIONS

In the case of SA occlusion on the first stage, it is expedient to carry out endovascular recanalization followed by stenting. Our study revealed an increased risk of stent thrombosis or in-stent restenosis in patients with stents >40 mm.

Results of Transradial Subclavian Artery Percutaneous Interventions After Bilateral or Single Access

Percutaneous treatment of subclavian artery stenosis or occlusion has become more popular compared with surgical correction. We compared the early and late results of subclavian artery stenting with bilateral or single transradial access. From 2010 to 2015, we recruited 54 consecutive patients. In 35 cases, we used bilateral access, and in 19 cases, ipsilateral single access was used. Left subclavian artery was the culprit vessel in 72% of cases. There were more chronic total occlusions in the bilateral group (77% vs 21%, p = 0.0001). Transradial-only approach was used in all cases, except in 2 cases in the bilateral group where crossover to femoral access was required. Stents were implanted in 94% in bilateral group and 84% in single group (p = 0.47). Procedure duration (40 [35 to 60] vs 20 [15 to 30] minutes), contrast volume (200 [200 to 350] vs 150 [100 to 200] ml and fluoroscopy time (20 [12 to 30] vs 8 [4 to 11] minutes) were higher in bilateral group (all p values <0.0001). Procedural success was 96%. Overall, we observed three <5-cm hematomas and 3 asymptomatic radial artery occlusions at hospital discharge. After successful procedure, blood pressure equalized in 94% in bilateral group and 100% in single group (p = 0.54). Major cardiovascular and cerebrovascular event-free survival up to 5 years was 97% in bilateral group compared with 84% in single group (p = 0.12). Subclavian artery patency at late follow-up was 91% in bilateral group and 95% in single group (p = 1.00). Using single or bilateral transradial approach, subclavian artery lesions or occlusions can be effectively and safely treated without the risks of femoral or brachial access.

Endovascular Therapy of Symptomatic Innominate-Subclavian Arterial Occlusive Lesions

The purpose of this study was to determine the safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions by review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the innominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical examination (pulses and blood pressures) at 1, 3, 6, and then every 12 months plus an annual duplex ultrasound examination. Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48 to 89 years. Symptoms included vertebrobasilar/steal (15), claudication (6), ischemia (4), and coronary artery bypass grafting/left internal mammary artery (2). There were 7 occlusions and 20 high-grade stenoses. Access was attempted via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (10). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 occluded lesions could not be crossed owing to complete occlusion. The remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic blood pressure between upper limbs decreased from 36 mm Hg (preprocedure) to 10 mm Hg (postprocedure). There were no procedure-related complications. Mean follow-up was 18 months (range 1–62 months). One patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the percutaneous transluminal angioplasty/stent. Of the 4 successfully treated occlusions, 2 were followed up to 3 years with continued patency. Three patients developed recurrent stenoses documented by duplex examination. However, these patients remained asymptomatic and were not treated. Endovascular management of high-grade lesions of the subclavian or innominate arteries is safe and efficacious and may be considered as a first line of therapy. Continued follow-up is needed to assess long-term patency.

Angioplasty and Stenting versus Carotid-Subclavian Bypass for the Treatment of Isolated Subclavian Artery Disease

Purpose:

To compare the results of a large series of percutaneous transluminal angioplasty (PTA)/stenting procedures in the subclavian artery with the results of a series of carotid-subclavian by pass grafts (CSBG) performed at the same institution for subclavian artery disease.

Methods:

Between 1993 and 2006, 121 patients (43 men; mean age 63 years, range 38–85) underwent subclavian artery PTA/stenting and were compared to a group of 51 patients (29 men; mean age 62 years, range 46–75) with isolated subclavian artery occlusive disease treated with CSBG using polytetrafluoroethylene grafts. Graft or PTA/stenting patency was determined clinically and confirmed by Doppler pressures and/or duplex ultrasound/angiography. The cumulative patency and overall survival rates were calculated using the life-table method.

Results:

The mean follow-up for the PTA/stent group was 3.4 years versus 7.7 years for the CSBG group. The technical success rate for the CSBG group was 100% versus 98% (119/121) for the PTA/stent group. The overall perioperative complication rate in the stent group was 15.1% (18/119: 11 minor and 7 major complications) versus 5.9% (3/51: 2 phrenic nerve palsy and 1 myocardial infarction) in the bypass group (p=0.093). There was no perioperative stroke or mortality in the CSBG group. The major perioperative complications in the stent group included 4 thromboembolic events, 1 congestive heart failure, 1 reperfusion arm edema, and 1 pseudoaneurysm. There was 1 perioperative death in the stent group. The 30-day patency rate was 100% for the bypass group and 97% (118/121) for the PTA/stent group. The primary patency rates at 1, 3, and 5 years were 100%, 98%, and 96% for the CSBG group versus 93%, 78%, and 70% for the stent group, respectively (p<0.0001). Freedom from symptom recurrence was also statistically superior in the bypass group versus the stent group (p<0.0001). There were no significant differences in the survival rates between both groups at any time point (p=0.322).

Conclusion:

Both CSBGs using PTFE grafts and subclavian PTA/stenting are safe, effective, and durable; however, CSBG is more durable in the long term. PTA/stenting of the subclavian artery should be the procedure of choice for high-risk patients; however, CSBG should be offered to good-risk surgical candidates who may be seeking a more durable procedure.

Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique

Background

In total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique.

Methods and results

Total arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients.

Conclusions

The modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it’s placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair.

Effective emergent endovascular recanalization for acute coronary syndrome with left subclavian artery occlusion in a prior coronary artery bypass graft patient

A 78-year-old female was hospitalized because of multiple bone fracture caused by falling down. She undertook coronary artery bypass graft (CABG) using left internal mammary artery (LIMA) about 10 years ago. She complained chest pain on the day of admission with hypotension. Emergent angiogram revealed total occlusion of left subclavian artery (SCA). We re-canalized left SCA with stent. Hemodynamics and symptom dramatically improved after the procedure. Acute coronary syndrome due to SCA occlusion after CABG using LIMA was rare, but we have to consider the possibility. Endovascular therapy to SCA lesion might be a proper strategy for these cases.

A review of subclavian steal syndrome with clinical correlation

Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.

Subclavian artery stenosis: a review for the vascular medicine practitioner

Peripheral artery disease assessment typically focuses on the evaluation of lower extremity symptoms and physical findings. Few practitioners consider the importance of upper extremity arterial disease; which, besides causing hand and arm symptoms, can be associated with significant neurologic and cardiac sequelae. A review of the existing literature through PubMed using the search term 'subclavian stenosis' was performed. The latest original articles, including clinical studies, case reports and limited reviews of this topic were adapted. A comprehensive article review focusing on the diagnostic and treatment approach for subclavian stenosis was prepared. In conclusion, vascular medicine practitioners including cardiologists and vascular surgeons caring for patients with arterial disease should routinely assess for subclavian stenosis. There are excellent screening tools and effective medical therapies which can be instituted if diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness.

Extensive Primary Repair of the Thoracic Aorta in Acute Type A Aortic Dissection by Means of Ascending Aorta Replacement Combined With Open Placement of Triple-Branched Stent Graft

Background—

To simplify extensive primary repair of the thoracic aorta in acute type A aortic dissection, we developed the open triple-branched stent graft placement technique. The early results of this new technique are reported.

Methods and Results—

Between June 2008 and November 2009, 30 patients with acute Stanford type A aortic dissection underwent extensive primary repair of the thoracic aorta by means of ascending aorta replacement combined with open placement of triple-branched stent graft. Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time, and lower body arrest time were 151.8±16.69, 84.1±6.97, and 31.17±5.34 minutes, respectively. The postoperative mechanical ventilation support period and duration of intensive care unit stay were 17.93±2.35 and 62.10±9.24 hours, respectively. All implanted stent grafts were fully opened and not kinked; there was no space or blood flow surrounding the triple-branched stent graft and no sidearm graft stenosis or occlusion. The false lumen of the descending aorta distal to the stent graft closed with thrombus in 25 of 30 patients at their first postoperative scans and in 26 of 30 at the 3-month postoperative scan.

Conclusions

Open triple-branched stent graft placement is an effective technique with satisfactory early results. With this technique, extensive primary repair of the thoracic aorta may become easier and safer for acute type A aortic dissection.

Claudication pain in the left arm of a coronary artery bypass graft patient using crutches: Coronary subclavian steal syndrome - a case report

A 77-year-old male former smoker with hypercholesterolemia and diabetes, who underwent coronary artery bypass graft surgery three years before admission and right carotid endarterectomy four years before admission, presented with recent-onset exertional chest pain. His medical history revealed that the chest pain was preceded by gradually worsening exertional claudication pain in his left arm when he was using crutches. The chest pain was similar to the pain he experienced before the coronary artery bypass graft surgery was performed. Coronary angiography and bypass graft imaging showed significant stenosis of the left subclavian artery proximal to the origin of the left internal mammary artery bypass, decreased flow in the left internal mammary artery with partial retrograde filling from the left anterior descending artery, and severe narrowing of the left vertebral artery with preserved centrifugal flow. Percutaneous stent implantation into the left subclavian artery was performed together with proximal balloon angioplasty of the left vertebral artery. The patient has been symptom free since the stent implantation.

Endovascular treatment of innominate artery stenosis via the bilateral brachial approach

Endovascular treatment (stenting) has evolved as an effective and safe treatment modality for symptomatic subclavian and innominate artery disease. Most of these patients have comorbid conditions associated with atherosclerotic vascular disease, which is responsible for the access site and increased difficulty of procedure. We report a case of symptomatic innominate artery stenosis with concomitant atherosclerotic disease of the abdominal aorta successfully treated with using coronary devices and the pull-through technique via the bilateral brachial approach.

Variant of subclavian steal in the setting of ipsilateral common carotid artery occlusion: case report

Subclavian steal is a well-described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.

Stenting for Left Subclavian Artery Stenosis before and after Coronary Artery Bypass Grafting Using the Internal Mammary Artery: A Report of Three Cases

SUMMARY

Stenosis of the subclavian artery proximal to the origin of the internal mammary artery (IMA) used for coronary artery bypass grafting may produce flow reversal (steal syndrome) and cause myocardial ischemia. We present three cases of subclavian artery stenosis proximal to the IMA before and after CABG. The first case developed symptomatic myocardial ischemia resulting from a variant of coronary-subclavian steal syndrome. The second case had asymptomatic subclavian artery stenosis proximal to the IMA used for CABG. In the third case we planned to perform CABG using the left IMA to treat cardiac ischemia. All of the patients were successfully treated by stent placement without the use of a protection device. In the first and second cases, cardiac ischemia did not appear during balloon inflation of the subclavian artery and no embolic complication occurred. In the third case, CABG was performed six months after stenting. Subclavian artery stenting is a valid alternative to surgical treatment to restore the flow to the IMA before or after CABG.

Subclavian artery revascularization: an outcome analysis based on mode of therapy and presenting symptoms

Therapy for atherosclerotic occlusive subclavian arterial disease is undergoing a paradigm shift from open to endoluminal therapy. The aim of this study was to review the changing patterns of presentation and clinical outcomes based on presenting symptoms of subclavian artery revascularization. We performed a retrospective analysis of consecutive patients treated for symptomatic atherosclerotic occlusive subclavian arterial disease from 1992 through 2006. Mean follow-up was 4 years. One hundred fourteen patients with a mean age of 63 years (range 33-89, 61% female) underwent 137 procedures. Of these, 89% had hypertension, 32% were diabetic, 69% had hyperlipidemia, and 13% had chronic renal insufficiency. Sixty-seven primary stent attempts (five technical failures) and 70 open (64 carotid-subclavian bypasses, six subclavian-carotid transpositions) were performed. No deaths occurred within the 30-day perioperative period. Fifty-seven percent of the patients presented with symptoms of arm ischemia: exertional pain (84%), rest pain (12%), and ulceration (4%). The assisted primary patency was 81 +/- 7% and 80 +/- 10% at 5 and 10 years, respectively. Symptoms resolved in all patients, and none required major or minor amputations. Freedom from recurrent arm symptoms was 71 +/- 8% and 71 +/- 10% at 5 and 10 years, respectively. Twenty-five percent of the patients presented with a cardiac indication: preparation for a left internal mammary artery (IMA) bypass in 61% and recurrent cardiac ischemia in the remainder. The assisted primary patency was 97 +/- 6% at 5 years. No IMAs were abandoned in this group, and the freedom from recurrent cardiac symptoms related to IMA distribution was 79 +/- 10% at 5 years. Eighteen percent of patients presented with posterior circulation symptoms secondary to vertebrobasilar disease. The assisted primary patency was 100 +/- 0% and 100 +/- 0% at 5 and 10 years, respectively. Freedom from recurrent vertebrobasilar symptoms was 95 +/- 6% and 95 +/- 10% at 5 and 10 years, respectively. Subclavian artery revascularization is safe and effective, but long-term outcomes are determined by the presenting symptomatology.

Prevalence and treatment of proximal left subclavian artery stenosis in patients referred for coronary artery bypass surgery

The left internal mammary artery (LIMA) is currently used in most coronary artery bypass graft (CABG) surgeries due to excellent long-term patency. Left subclavian artery stenosis (SAS) proximal to the LIMA origin can cause a steal syndrome leading to myocardial ischemia or LIMA failure. We retrospectively evaluated the records of 608 consecutive patients referred for CABG at our institution between October 1, 2004 and October 1, 2006 and identified 226 patients (37%) who underwent left subclavian angiography immediately after diagnostic coronary angiography. Significant left SAS was found in 6 of those 226 patients (2.7%). Subclavian angiography did not result in any complications. All left SAS lesions were successfully stented, followed by CABG surgery (using the LIMA artery) after 22+/-7 days. Left subclavian angiography in patients referred for coronary artery bypass surgery has low risk and may identify a small proportion of patients with significant proximal left SAS. Stenting of proximal left SAS can be accomplished before CABG with low risk and excellent short-term outcomes.

Endovascular treatment of vertebral artery-origin and innominate/subclavian disease: indications and technique

Approximately 20% to 40% of patients who have cerebral vascular disease have a vertebral artery-origin stenosis. Atherosclerotic lesions of vertebral arety origin are a potential cause of posterior circulation ischemia, which can be disabling or deadly. Endovascular treatment of vertebral artery-origin and innominate/subclavian artery stenosis has changed in the last 15 years. Surgery usually is successful technically; however, it is also associated with high rates of procedural and periprocedural complications. New techniques and technologies that can be used in the treatment of such lesions are being developed. In this article, the authors discuss the indications, technical aspects, and long-term results of angioplasty and stenting of these vessels.