Percutaneous transluminal angioplasty and stent placement for subclavian and brachiocephalic artery stenosis in aortitis syndrome

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.

Left main coronary occlusion from Takayasu arteritis in an 8-year-old child

Takayasu's arteritis (TA) is a chronic systemic inflammatory disease that usually affects the aorta and its primary branches and occasionally the coronary arteries. We report the case of an 8-year-old girl who was presented with chest pain and was referred to our institution with the presumptive diagnosis of pneumonia and sepsis. Ultimately, the patient's chest pain was attributed to myocardial infarction secondary to coronary occlusion from TA. She underwent a successful stenting of the left main coronary artery with sirolimus-eluting stent. In a review of the literature, we discuss the demographic profile, clinical and radiographic findings, and available therapeutic options.

Endovascular Treatment of Supra-Aortic Extracranial Stenoses in Patients with Vertebrobasilar Insufficiency Symptoms

PURPOSE

Stenoses and thromboses of vessels feeding the vertebrobasilar territory can evoke serious disturbances including ischemic stroke. We present our experience of endovascular interventions for patients with signs of vertebrobasilar insufficiency (VBI) resulted from subclavian, vertebral and brachiocephalic arterial stenoses.

METHODS

Twenty-one patients (10 men) aged from 35 to 84 years (mean 64.3 years) with symptoms compatible with VBI underwent balloon angioplasty and stenting of subclavian (SA), innominate (IA) and vertebral (VA) arteries. Procedures were done by radiologists experienced in systematic stenting of the lesions. VBI was manifested by persistent signs in 15 patients, and by transitory ischemic attacks in the posterior circulatory territory in 4 (19%). Two patients (10%) experienced ischemic strokes (in the vertebrobasilar circulation in both cases). In 3 patients (14%) VBI was accompanied by upper limb vascular insufficiency symptoms. All cases were resistant to medical treatment. A neurologist assessed complaints, initial VBI signs and their alteration after intervention in all patients. Outcomes were measured with the 5-point scale suggested by Malek et al.: (1) excellent result (asymptomatic, no neurologic deficits and no symptoms of vertebrobasilar ischemia); (2) good (no neurologic deficits, at most one transient episode of vertebrobasilar ischemia over a period of 3 months after treatment); (3) fair (minimal neurologic deficit and at most one transient episode per month of vertebrobasilar ischemia); (4) poor (no improvement compared with neurologic status before treatment and/or persistent symptoms of vertebrobasilar ischemia); (5) death (regardless of cause). Endovascular treatment was performed for SA stenosis in 15 patients, for SA occlusion in 2, for IA stenosis in 2, and for VA stenosis in 2. There were 15 cases of atherosclerosis, 2 of aortoarteritis, 4 of proximal SA kinking. SA and IA stenoses ranged from 60% to 100% (mean 74.5%), VA stenoses were 90% in both cases.

RESULTS

Initial technical success was achieved in 96% of cases. There were no postprocedural complications or deaths. During 6-36 months (mean 21.3 months) of follow-up all patients showed improvement in VBI symptoms or upper limb ischemia. Within 36 months after the procedure outcomes were estimated as excellent and good in 13 patients (76%) and poor in 2 (12%), the last being attributed to atherosclerosis progression in other vascular areas. Restenosis in the stented area has developed in 1 patient (6%).

CONCLUSIONS

Balloon angioplasty and stenting of extracranial vertebrobasilar arterial stenoses appeared to be effective in endovascular treatment of medically resistant VBI. Further investigations are required to clarify the role of subclavian artery kinking in VBI development and indications for various methods of its correction.

Use of Stents to Treat Extracranial Cerebrovascular Disease

Stent-assisted carotid angioplasty (CAS) is increasingly utilized for hemodynamically significant stenoses of the extracranial carotid artery. Carotid endarterectomy (CEA) is still considered the gold standard in the management of symptomatic hemodynamically significant carotid stenoses. However, endovascular device technology is rapidly evolving and the recent introduction of embolic filtration devices (EFD) proved to reduce periprocedural stroke rates in CAS considerably. Several randomized multicenter trials are currently recruiting patients to compare CAS with EFD to carotid endarterectomy in different cohorts, such as patients at high surgical risk for CEA and those with asymptomatic stenosis. The review presents current developments in CAS.

Sirolimus-eluting stent for in-stent restenosis of left main coronary artery in takayasu arteritis

A 53-year-old woman with Takayasu arteritis was admitted to hospital because of worsening exertional angina. Coronary angiography revealed 90% ostial stenosis in the left main coronary artery (LMCA), which also involved the bifurcation of the relatively short LMCA. Because the patient refused coronary bypass surgery, she underwent percutaneous coronary intervention (PCI) and the stenosis was successfully dilated. However, the exertional angina recurred a few months later and again after the second PCI. Finally, a sirolimus-eluting stent was deployed in the in-stent restenotic lesion. The patient has been free from angina pectoris for 6 months after the last PCI and follow-up coronary angiography indicated no restenosis in the LMCA.

Extracranial revascularization therapy: Angioplasty and stenting

Beginning with simple balloon angioplasty, minimally invasive revascularization techniques have progressed to the use of metallic stents for improved immediate and long-term results. Stent-supported angioplasty now offers a therapeutic option for those individuals ineligible for surgical revascularization of stenotic atherosclerotic lesions and who have failed maximal medical therapy. However, the clinical equivalence, or possibly even superiority, of angioplasty of the extracranial carotid and vertebral arteries in atheromatous occlusive disease over surgical revascularization has yet to be determined in ongoing randomized controlled trials. Additionally, endovascular techniques offer treatment for a variety of nonatherosclerotic disease affecting the extracranial arteries, such as inflammatory, radiation-induced, and postsurgical strictures; acute intimal dissection; traumatic and spontaneous arteriovenous fistulas; and aneurysms or pseudoaneurysms. For certain disease entities at high risk for surgical complications, endovascular procedures have gained preference as the therapeutic modality of choice, yet lacking controlled trials providing evidence for noninferiority against surgical approach. Continued innovation and refinement of endovascular technology and techniques will further improve technical success, reduce procedure-related morbidity, and broaden the endovascular therapeutic spectrum for extracranial and intracranial cerebrovascular disease.