Initial and Long-Term Results of Endovascular Therapy for Chronic Total Occlusion of the Subclavian Artery

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.

Balloon-hooking technique for stabilizing a guiding catheter in tortuous supra-aortic vessel: A case report

Objective: When performing endovascular interventions for supra-aortic vessels, the tortuous vascular anatomy observed in patients with atherosclerotic lesions often limits the ability to maintain a stable guiding catheter position. Here, we report a case of right vertebral artery (VA) stenosis treated with transfemoral stenting and discuss the utility of balloon-hooking technique using partially inflated balloon for stabilizing the balloon guiding catheter (BCG) in the supra-aortic vessel. Case presentation: A 74-year-old man who underwent right carotid artery stenting, coronary artery bypass grafting, and bilateral iliac artery stenting was admitted to our emergency department because of dizziness related to head movement. Computed tomography angiography revealed right VA origin stenosis and left subclavian artery (SA) occlusion. The patient underwent stenting of the right VA. After several unsuccessful cannulation attempts into the right VA through transradial access, transfemoral access was obtained through the left iliac stent. A 9-Fr BGC was navigated into the right SA. The balloon was partially inflated just distal to the first curve of the right SA and used as hook by pulling back until the proximal edge of the balloon was pushed distally by the lesser curvature of the SA, resulting in stabilization of the BGC and successful angioplasty and stent deployment at the VA stenosis. The patient's symptoms resolved completely, without any neurological deficits. Conclusions: Balloon-hooking technique using a partially inflated BGC is feasible for stabilizing the guiding catheter in tortuous supra-aortic vessel.

Carotid-Vertebral or Carotid-Subclavian Transpositions in Supra-Aortic Steno-Occlusive Diseases When Endovascular Therapy Is Unfeasible or Unsuccessful

Background and purpose

Despite advances in endovascular therapies, some patients experience vertebral artery stenosis or subclavian artery occlusion and may not benefit from less-invasive angioplasty/stenting. This study described 4 cases in which carotid-vertebral transposition (CVT) or carotid-subclavian transposition (CST) was adapted when endovascular treatment was unfeasible or unsuccessful.

Presentation

Case 1: A 65-year-old woman presented with severe stenosis of the right vertebral artery ostium, dysplastic left vertebral artery, and aneurysmal dilatation of proximal right subclavian artery and brachiocephalic trunk. Case 2: A 23-year-woman had severe stenosis at the first portion of left vertebral artery caused by Takayasu's arteritis. Because endovascular intervention was unfeasible, CVTs were performed in cases 1 and 2. Case 3: A 73-year-old man presented with total occlusion of the proximal right subclavian artery and severe stenosis of the right internal carotid artery. Case 4: A 58-year-old man experienced complete occlusion of the left subclavian artery and severe stenosis of the left common carotid artery. Duplex ultrasonography showed reverse flow in the vertebral artery in keeping with vertebral steal syndrome. Endovascular treatment was unsuccessful because the wire did not cross the occlusion of the subclavian artery. CSTs were performed with concurrent ipsilateral carotid endarterectomy in cases 3 and 4.

Conclusion

The present case series demonstrated that CST and CVT were effective treatment modalities for subclavian or vertebral artery lesions. Although endovascular stenting and angioplasty have been advocated as first-line management, CST and CVT should be considered as the remedy when endovascular intervention is unsuccessful or unfeasible.

Combined Transradial and Transfemoral Approach With Ostial Vertebral Balloon Protection for the Treatment of Patients With Subclavian Steal Syndrome

Background: Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1–5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA.

Objective: To assess the safety and feasibility of a novel technique for distal embolic protection using balloon catheters during SA revascularization with a dual transfemoral and transradial access.

Methods: We describe a case series of patients with SSS who underwent SAPTA due to severe stenosis or occlusion of the SA using a combined anterograde/retrograde approach. Transfemoral access to SA was obtained using large bore guide sheaths. Ipsilateral transradial access was obtained using intermediate bore catheters. A Scepter XC balloon catheter was introduced through the transradial intermediate catheter into the ipsilateral VA at the ostium during SAPTA for distal embolic protection.

Results: A total of eight patients with SSS underwent subclavian SAPTA. Four patients had the combined anterograde/retrograde approach. Successful revascularization was achieved in three of them. It was difficult to create a channel in the fourth unsuccessful case due to heavily calcified plaque burden. No peri-operative ischemic events were identified. On follow-up, we demonstrated patency of the stents with resolution of symptoms and without any adverse events.

Conclusion: Subclavian stenting using a combined transradial and transfemoral access with compliant balloon catheters at the vertebral ostium for prevention of distal emboli may represent an alternative therapeutic approach for the treatment of SA stenosis and occlusions.

A Case of Recurrent Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome (CSSS) is one of the rare complications of coronary artery bypass graft surgery (CABG). This phenomenon is a potential complication after left internal mammary artery (LIMA) to left anterior descending artery (LAD) CABG. A proximal stenosis of the left subclavian artery (SA) could cause retrograde flow from LIMA to left SA, which characterizes the mechanism of CSSS. We describe a unique case of recurrent CSSS in a 64-year-old female who presented with one month of exertional dyspnea and acute onset chest pain. She had an extensive coronary artery disease history with CABG 15 years prior to presentation and CSSS treated with left SA stent placement nine years later. She also underwent percutaneous intervention with stents placed in the saphenous vein graft. Although electrocardiogram, cardiac enzymes, and stress test did not show any evidence of acute ischemic changes, perfusion scan detected large areas of partially reversible ischemia. Cardiac catheterization was performed, which showed in-stent restenosis of the left SA and retrograde flow from the LIMA to the left SA indicative of recurrence of CSSS. Left SA arteriogram confirmed in-stent restenosis of the left SA, which was treated with balloon angioplasty and stent placement.

Endovascular Treatment of Chronic Total Occlusion in the Subclavian Artery: A Review of 23 Cases

Objectives and Background: To review technical details and long-term outcomes of endovascular treatment of chronic total occlusion (CTO) of the subclavian artery. Methods: From January 2010 to May 2017, 23 patients (17 male; median age, 65 years) underwent endovascular treatment for CTO of the subclavian artery. All lesions had been diagnosed by duplex scanning or computed tomography angiography before treatment. Sixteen (70.0%) patients had symptoms of vertebrobasilar insufficiency, 6 (26.1%) patients had symptoms of arm ischemia, and 2 (8.7%) patients were asymptomatic. Duplex scanning revealed that 16 patients had grade 3 and 7 patients had grade 2 steal blood flow. After recanalization, lesions were treated by stenting. Patients were followed up at 1, 3, 6, and 12 months after endovascular treatment, and annually thereafter. Results: The overall technical success rate was 91.3% (21/23). The successful recanalization rate of antegrade and retrograde approaches were 68.2% (15/22) and 75.0% (6/8), respectively. The rate of clinical symptom remission was 95.2% (20/21) after treatment. No perioperative death or permanent neurological deficits were observed. One patient had arterial dissection treated by covered stent. The estimate cumulative primary and secondary patency rates at 5 years were 74.6 and 78.8%, respectively. Conclusion: Endovascular treatment is a feasible and safe treatment for CTO lesions of the subclavian artery.

Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery

INTRODUCTION

Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery.

METHODS

Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included.

RESULTS

Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery. 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted in 15 patients. Central luminal passage was not achieved in one patient because of the subintimal position of the guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. The patency rate at two years was 93.3%.

CONCLUSION

Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results.

Endovascular therapy of axillary artery disease with drug-coated balloon angioplasty

The occurrence of upper-extremity arterial disease is less common than that of the lower extremities. Nevertheless, exercise-induced symptoms, when present, can significantly affect functional capacity and limit quality of life. We report a case of exertional right upper-extremity pain and severe right axillary artery disease that was revascularized using an off-label drug-coated balloon technology with resolution of symptoms.

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.

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.

Ten-year experience in subclavian revascularisation. A parallel comparative observational study

Introduction

Subclavian stenosis has a prevalence of approximately 2% in the community, and 7% within a clinical population. It is closely linked with hypertension and smoking. There is a relative paucity of published data to inform clinicians on the optimal mode of treatment for subclavian artery stenosis.

Objectives

To compare clinical outcomes of subclavian bypass surgery with that of subclavian endovascular re-vascularisation. Endpoints were survival time, re-intervention-free survival, and symptom-free survival.

Method

In all, 21 subclavian interventions were performed from 2000 to 2010. We compared angioplasty vs angioplasty with stenting vs bypass.

Results

Technical success was 100% in all groups. Symptom-free survival, at 70 months, was 60% in the angioplasty group, 100% in the angioplasty and stenting group and 75% in the bypass group. Re-intervention rate was 40% in the angioplasty group, 0% in the angioplasty and stenting group and 25% in the bypass group. Median time for re-intervention was 9.5 months in angioplasty patients and 36 months in bypass patients ( p = 0.102). Target lesion revascularisation was 20.0% for angioplasty procedures, 16.67% for angioplasty and stenting and 25% for bypass procedures.

Conclusion

Angioplasty with stenting provides improved symptom-free survival and freedom from re-intervention in patients with symptomatic subclavian artery stenosis.

Coronary subclavian steal syndrome

PURPOSE OF REVIEW

Coronary subclavian steal syndrome (CSSS) is the reversal of blood flow in an internal mammary artery bypass graft that results in coronary ischemia. CSSS is an uncommon but treatable cause of coronary ischemia. In this review, we highlight the historical background and epidemiology of CSSS, common clinical presentations, diagnosis of CSSS and management strategies for relieving ischemia. We also present a case report to illustrate the complexity of CSSS and percutaneous management using current technology.

RECENT FINDINGS

Most commonly, CSSS results from atherosclerotic stenosis of the subclavian artery and occurs in 2.5-4.5% of patients referred for coronary artery bypass grafting (CABG). All patients referred for CABG should have bilateral noninvasive brachial blood pressures checked to screen for the underlying subclavian stenosis. A review of 98 case reports with 128 patients demonstrated a diverse clinical presentation of CSSS, including acute myocardial infarction, unstable angina and acute systolic heart failure. Resolution of CSSS symptoms has been reported with both surgical and percutaneous revascularization. Long-term patency with either revascularization strategy is excellent. Percutaneous revascularization is largely considered the first-line therapy for CSSS and can be safely performed prior to CABG to prevent CSSS.

SUMMARY

CSSS should be suspected in patients presenting with angina, heart failure or myocardial infarction after CABG. Successful amelioration of CSSS symptoms can be safely and effectively performed via percutaneous revascularization.

Coronary Subclavian Steal Syndrome: An Unusual Cause of Angina in a Post-CABG Patient

Coronary subclavian steal syndrome is a rare complication of coronary artery bypass grafting surgery (CABG) when a left internal mammary artery (LIMA) graft is utilized. This syndrome is characterized by retrograde flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. We describe a unique case of an elderly male who underwent CABG 6 years ago who presented with prolonged chest pain, mildly elevated troponins, and unequal pulses in his arms. A CTA of the chest demonstrated a severely calcified occluded proximal left SA jeopardizing his LIMA graft. Subclavian angiography was performed with an attempt to revascularize the patient's occluded left SA which was unsuccessful. We referred the patient for nuclear stress testing which demonstrated a moderate size area of anterior ischemia on imaging; the patient exercised to a fair exercise capacity of 7 METS with no chest pain and no ECG changes. Subsequent coronary angiography showed severe native three-vessel coronary artery disease with intermittent retrograde blood flow from the LIMA to the left SA distal to the occlusion, jeopardizing perfusion to the left anterior descending (LAD) coronary artery distribution. He declined further options for revascularization and was discharged with medical management.

Retrieval of a malpositioned left subclavian artery stent from the ascending aorta: combined percutaneous and surgical management

Chronic upper limb ischemia is an uncommon clinical condition and is most often caused by subclavian artery stenosis. Surgical and percutaneous treatment modalities have been shown to be effective for the management of subclavian artery occlusion. Because of lower mortality and morbidity rates, percutaneous interventions for subclavian arterial occlusions are more acceptable than surgery. Chronic total occlusions of the subclavian artery are challenging to treat percutaneously because of the structure and complexity of the lesion. The complexity of the lesion causes its own complications. In this paper, we report a case of a completely occluded left subclavian artery that was complicated by a malpositioned stent hanging into the aortic arch and the ascending aorta during percutaneous intervention, which was successfully managed by our heart team.

A case of cerebellar infarction caused by acute subclavian thrombus following minor trauma

Subclavian steal syndrome caused by an acute thrombus is very rare. We present a case of cerebellar infarction with proximal subclavian artery thrombosis. A 56-year-old woman was admitted for sudden vertigo. One day prior to admission, she received a shoulder massage comprised of chiropractic manipulation. On examination, her left hand was pale and radial pulses were absent. Blood pressure was weak in the left arm. Downbeat nystagmus and a right falling tendency were observed. Brain MRI showed multiple acute infarctions in the left cerebellum. The findings of Doppler ultrasonography in the left vertebral artery were compatible with a partial subclavian artery steal phenomenon. Digital subtraction angiography demonstrated a large thrombus in the left subclavian artery. After heparin infusion, thrombus size markedly decreased. Cerebellar infarction caused by acute subclavian thrombosis following minor trauma is rare, but the thrombus can be successfully resolved with anticoagulation.

Carotid-brachial bypass and simultaneous radiocephalic fistula for a patient on hemodialysis

Patients undergoing long-term hemodialysis often suffer from obliterative arterial disease, which may lead to hand ischemia and/or access failure. We present the case of a 54-year-old female patient with multiple failures in obtaining vascular access. Computed tomography angiogram revealed a long occlusion of the axillary artery. Vein mapping through duplex scanning demonstrated a suitable cephalic vein in the left forearm. A left carotid-brachial bypass was performed with simultaneous radiocephalic arteriovenous fistula formation. Immediate results were excellent, and the postoperative course was uneventful. To our knowledge, this is the first report of such a combined approach.

A diabetic patient with asymptomatic multiple arterial disease

The authors present the case of a 73-year-old diabetic woman who was referred to hospital because of the suspicion of lower limb peripheral arterial stenosis. During evaluations signs of the subclavian artery occlusion were found. In addition to diabetes, the patient had several risk factors revealed by medical history. Subclavian artery occlusion was solved by angiography guided stenting, and angiography also showed the presence of abnormalities in renal arteries. This case draws the attention to the importance of screening old diabetic patients for arterial stenosis and the importance of accurate risk factor assessment. Orv. Hetil., 2012, 153, 1475–1479.

Endovascular stenting for atherosclerotic subclavian artery stenosis in patients with other craniocervical artery stenosis

Atherosclerotic subclavian artery stenosis (SAS) accompanied with other craniocervical artery stenosis (OCAS) is not uncommon in practice. We sought to investigate the safety and efficacy of endovascular stenting for SAS in patients with OCAS. Between January 2004 and February 2012, 71 consecutive atherosclerotic SAS patients who underwent primary stenting in our medical center were included. The enrolled patients were divided into combined-SAS group (n = 51) and solitary-SAS group (n = 20) depending on the presence or absence of OCAS. Data of demographics, procedure, and the followed-up were retrieved and analyzed. The technical success rate was 95.8%; the clinical success rate was 90.1%. There was no catheter-related major stroke or death. The immediate outcomes had no statistical difference between groups. During a mean of 27 ± 20 months (range 2-88 months) followed-up, 7 (10.3%) restenosis and 12 (17.6%) clinical events were identified. The primary patency rate was 95.3, 84.9 and 84.9% at 12, 24 months, and final followed-up respectively, which had no statistical difference between groups (odds ratio (OR), 2.60; 95% confidence interval (CI), 0.54-12.53; P = 0.232). The overall clinical event-free survival rate was 93.5, 86.2 and 54.6%, respectively, where the result of combined-SAS group was inferior to that of the solitary-SAS group (OR, 3.34; 95% CI, 1.02-11.00; P = 0.047). Endovascular stenting was safe and feasible for atherosclerotic SAS in patients with OCAS, although the combined OCAS may have a significant influence on the long-term outcome. Further studies are warrant to investigate the effects of revascularization for multiple craniocervical artery stenoses on the cerebral hemodynamics and long-term outcomes.

Annotating proteins from endoplasmic reticulum and Golgi apparatus in eukaryotic proteomes

The sub-cellular localization of a native protein constitutes one coarse-grained aspect of its function. Transport between compartments is often regulated through short sequence motifs. Here, we analyzed experimentally characterized endoplasmic reticulum (ER)/ Golgi retrieval motifs and investigated the accuracy of homology-transfer. Only the C-terminal ER retrieval motifs KDEL, HDEL and AIAKE were sufficiently specific. However, even unspecific motifs may help, provided we know the probability for localization given the motif. We provided such estimates. We also rigorously estimated the accuracy and coverage for inferring ER and Golgi localization through homology-transfer by sequence similarity. In entire proteomes, we could thereby annotate 3304 ER (3182 membrane) and 1853 Golgi (759 membrane) proteins. We identified another putative 5157 globular and 3941 membrane ER or Golgi proteins. Each experimental annotation yielded, on average, one to three high-accuracy and five to six low-accuracy homology-transfers in the six proteomes. These numbers will increase with each new experimental annotation.