Stenting for atherosclerotic occlusive disease of the subclavian artery

Hospitalized upper extremity artery disease patients: treatment and long-term outcomes

BACKGROUND AND AIMS

Current knowledge about upper extremity artery disease (UEAD) is scarce. This study aimed to evaluate the prevalence, treatment patterns, and short- and long-term outcomes of patients suffering from UEAD.

METHODS

Retrospective health claims data of patients who were hospitalized with a primary diagnosis of UEAD between 2010 and 2017 were analysed. The data were obtained from 11 legally independent statutory health insurance funds of the 'AOK-Die Gesundheitskasse'. Risk factors, comorbidities, pharmacotherapy, revascularization procedure, and outcome were evaluated with a particular focus on sex-related disparities (median follow-up time: 5.5 years).

RESULTS

Among 2437 UEAD patients (43% female, median age of 67 years), 80% were solely atherosclerotic (UEADa), while 20% had concomitant inflammatory/connective tissue diseases (UEADc/i). Cardiovascular risk factors and comorbidities were highly prevalent in both sexes. Coronary, cerebrovascular, and lower extremity artery diseases and organ failure such as chronic kidney and heart failure were more frequent in men compared with women. At index stay, women had higher rate of revascularization than men (37% vs. 27%). The 5 year mortality among the entire population was almost 50%, even higher in men (UEADa: 51% vs. 36% P < .001; UEADc/i: 44% vs. 36%, P < .05). Furthermore, men had higher rates of upper limb amputation compared with women despite equal secondary preventive pharmacotherapy (UEADa: 26% vs. 11%, P < .001; UEADc/i: 30% vs. 18%, P < .01).

CONCLUSIONS

Upper extremity artery disease patients, irrespective of the underlying disease type, face a poor prognosis with elevated proportion of amputation and mortality. Male sex was linked to increased risk of future cardiovascular and limb events including death. Further investigation is warranted to understand the underlying causes of the sex-related disparities and identify treatment improvements.

Clinical outcomes of a balloon-expandable stent for symptomatic obstructions of the subclavian or innominate arteries

Background: Upper-extremity peripheral arterial disease (PAD) may present with a broad spectrum of signs and symptoms. If an endovascular treatment is planned, percutaneous angioplasty and stent placement may lead to a better patency compared to percutaneous angioplasty alone. We assessed the characteristics and clinical course of patients with upper-extremity PAD who received angioplasty and a balloon-expandable stent. Patients and methods: We analyzed data from consecutive patients treated with angioplasty and placement of a balloon-expandable BeSmooth Peripheral Stent System® (Bentley, Germany) at the Angiology Department (University Hospital Zurich) between 2018 and 2022. The primary outcome was re-intervention at the target lesion within 6 months from index angioplasty and during available follow-up. The study was approved by the local ethical commission. Results: A total of 27 patients were treated. The median age was 70 (Q1-Q3: 60-74) years and 59% were men. The subclavian artery (74%) represented the most frequently treated target lesion, followed by the innominate artery (26%). The mean improvement in blood pressure in the treated arm was 21 (95%CI 7 to 35) mmHg at 24 hours and 29 (95%CI 15 to 43) mmHg at 6 months. At 6 months, 2 (8%) patients required a target lesion re-intervention. During the remaining follow-up period up to 24 months, one of these two patients required additional intervention and a total of 3 (11%) patients died due to sepsis, cancer, and unknown causes, respectively. Conclusions: Percutaneous catheter-based treatment with a balloon-expandable stent for symptomatic upper extremity PAD appeared to be effective and safe.

Navigating Subclavian Artery Stenosis in Pregnancy: A Multidisciplinary Approach to a High-Risk Case

Given the possibility of serious consequences for both the pregnant woman and the developing baby, subclavian artery stenosis (SAS) during pregnancy represents a unique but demanding scenario that requires quick and thorough treatment. In this report, we present a case of a pregnant patient with SAS who was managed effectively by employing a multidisciplinary approach, with a focus on clinical decision-making and intervention measures to ensure the best possible outcomes for both the mother and the fetus. This case report highlights the significance of prompt recognition and action to avoid the adverse consequences of SAS during pregnancy. To establish uniform standards for managing such high-risk cases and achieve better patient outcomes, more research and case studies are required.

Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review

Introduction

Subclavian steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal ipsilateral subclavian artery.

Materials and methods

Four patients with subclavian steal syndrome were treated in our center. Percutaneous radial approach was used for angioplasty, primary stenting of subclavian artery was performed, surgical techniques in particular carotid-subclavian bypass and carotid-subclavian transposition were used.

Results

We report the cases of four patients, three of which are male, with an average age of 60 years. All of them were symptomatic. Diagnosis was made by duplex ultrasound, supplemented by CT-angiography and arteriography. Endovascular treatment was attempted in all four patients, which was successful in two patients, who underwent primary stenting, and failed for the two others, for whom surgical treatment was considered. One had a subclavio-carotid bypass graft with a polytetrafluorethylene (PTFE) prosthesis and the other had a subclavio-carotid transposition. The technical results were satisfactory in all patients with symptoms resolution. The postoperative evolution was without notable complications and the postoperative checkups were satisfactory.

Discussion

There are excellent screening tools and effective medical therapies which can be instituted if the SSS is 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. Nevertheless, large, prospective, randomized and controlled trials are needed to compare the long-term patency rates between the endovascular and surgical techniques.

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SSS is caused by the reversal of blood flow in the vertebral artery.

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Doppler ultrasound is the ultimate screening tool for diagnosis.

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Treatment of symptomatic SSS is always indicated.

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Endovascular approach is the first-line treatment.

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.

Safety and durability of concomitant carotid endarterectomy with carotid-subclavian bypass grafting

BACKGROUND

Concomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution.

METHODS

Electronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group.

RESULTS

There were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%).

CONCLUSIONS

Concomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.

Carotid, Vertebral, and Brachiocephalic Interventions

Carotid atherosclerosis most frequently manifests in the proximal internal carotid artery and the common carotid artery bifurcations. Subclavian artery atherosclerosis affects the proximal segments with a relatively higher incidence on the left and becomes clinically important in the presence of vertebrobasilar insufficiency or coronary steal. Atherosclerosis of the vertebral artery can lead to posterior circulation stroke. The authors review the major trials on carotid carotid, brachiocephalic and vertebral artery stenosis along with the various available diagnostic and interventional techniques.

Percutaneous Transluminal Angioplasty of Subclavian Artery Lesions

Introduction:

Percutaneous transluminal angioplasty (PTA) is one of the treatment options for stenotic and obstructive lesions of the subclavian artery.

Aim:

To evaluate initial and long-term results of percutaneous transluminal angioplasty of subclavian artery lesions.

Methods:

During period February 2016 to December 2017, 26 patients (12 men and 14 women) with significant subclavian artery stenosis and occlusion were admitted and underwent PTA. All patients were symptomatic. All PTA procedures were performed with the patient under local anesthesia, through the femoral artery (n=22), brachial artery (n=4), or combined route (n=6). In 7 patients, we performed direct stenting, while in the other 15 patients we performed predilatation before stent implantation. The follow-up protocol consisted of regular clinical examinations in 1, 3, 6 and 12 months post-procedural, and annually thereafter with duplex ultrasound monitoring.

Results:

Initial technical success was achieved in 22 of 26 procedures (84.61%), 100% in stenotic lesions and 55.5 % in total occlusions. Fourth of nine occlusions could not be recanalized by PTA. These patients were managed surgically. The 30-day mortality rate was 0% for the entire group. No patients required reintervention for recurrence of symptoms and the stents remain patent at period of 12 months post-procedural.

Conclusion:

The minimal invasive technique, the markedly lower complication rate, the high long-term patency, patient’s comfort and the decreased hospital stay have made endovascular repair the primary choice of treatment in the majority of cases, especially in patients with stenotic lesions and high-risk patients. We consider PTA of subclavian artery stenotic/obstructive lesions should be the first therapeutic option.

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.

Use of a Re-entry Device in Left Subclavian Occlusion: Case Series

PURPOSE

To describe the use of a re-entry catheter in the endovascular treatment of left subclavian stenosis.

MATERIALS AND METHODS

We present three patients where initial attempts at re-vascularisation using standard techniques were unsuccessful. An OUTBACK catheter was employed to facilitate re-entry in these patients.

RESULTS

True lumen re-entry was achieved in all patients, leading to successful treatment of all stenoses. There was a lack of filling of the left vertebral artery post-angioplasty in one patient; this was not clinically significant.

CONCLUSION

The case series presented is encouraging for the use of a re-entry catheter in the treatment of subclavian occlusion. In our limited experience this has proved to be a safe technique for use in patients who fail re-vascularisation by standard methods; a larger study is required to confirm this.

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.

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.

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.

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.

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.

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.

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.

Perioperative and Long-term Outcomes of Endovascular Treatment for Subclavian Artery Disease From a Large Multicenter Registry

Purpose: To investigate the perioperative and long-term outcomes of endovascular therapy (EVT) for subclavian artery disease in a large-scale multicenter study. Methods: The study analyzed the outcomes from a multicenter retrospective registry (SubClavian Artery disease treated with endovascuLar therapy; muLticenter retrOsPective registry: SCALLOP) of 718 consecutive patients with upper extremity artery disease who underwent EVT between January 2003 and December 2012 at 37 Japanese cardiovascular centers. Of the 718 patients enrolled in the registry, 162 patients were excluded, leaving 553 patients (mean 70±7 years, range 41–91; 405 men) who underwent primary EVT for de novo subclavian artery disease (560 arms). Results: Procedure success was achieved in 96.8% (100% for stenoses, 91% for total occlusions). The perioperative complication rate was 9.2%. Stroke was found in 1.8%, with ipsilateral posterior infarction accounting for 0.9%. The 30-day mortality was 0.7%. The mean follow-up was 39±24 months. Primary patency estimates were 90.6%±1.3%, 83.4%±1.8%, and 80.5%±2.2% at 1, 3, and 5 years, respectively. There was no significant difference in primary patency between stenotic and occlusive lesions. Secondary patency estimates were 99.2%±0.4%, 98.2%±0.6%, and 97.7%±0.8% at 1, 3, and 5 years, respectively. The respective overall survival rates were 94.6%±1.0%, 86.8%±1.7%, and 79.0%±2.4%. There were 86 deaths during follow-up, of which half were due to cardiovascular causes. On multivariate analysis, critical hand ischemia (hazard ratio [HR] 4.6, 95% CI 2.06 to 10.2, p<0.001), cerebrovascular disease (HR 1.9, 95% CI 1.14 to 3.06, p=0.01), current smoking (HR 1.8, 95% 1.14 to 2.79, p=0.01), and lesion length (in 1-cm increments; HR 1.02, 95% CI 1.00 to 1.04, p=0.03) were negative independent predictors of primary patency, while IVUS use (HR 0.6, 95% CI 0.30 to 0.96, p=0.04) was a positive predictor of primary patency. Conclusion: Primary angioplasty/stenting for subclavian artery disease afforded acceptable outcomes in terms of perioperative complications and long-term patency.

Carotid artery stenting using a transapical approach for the treatment of radiation-induced carotid stenosis

Radiation-induced stenosis of the carotid artery is considered a challenging entity for direct revascularization. We performed a carotid artery stenting for a radiation-induced stenosis using a transapical approach on an asymptomatic 63-year-old male patient. Transapical approach, which is often used for cardiac surgery, was not yet described for the endovascular treatment of carotid stenosis. The transapical approach could be an attractive alternative path for patients presenting significant supra-aortic trunks lesions and unfit for direct approach or peripheral access. This case reports the feasibility and the safety of carotid artery stenting using the transapical approach in well-trained teams.

Angioplasty versus stenting for subclavian artery stenosis

BACKGROUND

There is insufficient evidence to guide stent usage following angioplasty in subclavian artery stenosis. This is an update of a review first published in 2011.

OBJECTIVES

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

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 1). There was no restriction on language.

SELECTION CRITERIA

Randomised controlled trials of endovascular treatment of subclavian artery lesions comparing angioplasty alone and stent implantation.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, the third author was asked to assess the study for inclusion.

MAIN RESULTS

To date we have not identified any completed or ongoing randomised controlled trials comparing 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.

Long-term results of primary stenting for subclavian artery disease

OBJECTIVES

To evaluate initial and long-term results of endovascular therapy (EVT) for symptomatic subclavian artery (SCA) disease.

BACKGROUND

EVT for SCA disease has a similar success rate as open surgery, but the long-term patency of EVT alone is uncertain.

METHODS

We retrospectively studied 59 consecutive patients (42 males and 17 females) with 60 lesions. Mean patient age was 68 ± 10 years. Clinical symptoms were vertebrobasilar insufficiency in 21 patients (35.0%), arm claudication in 20 patients (33.3%), angina pectoris in 12 patients (20%), severe arm ischemia in 3 patients (5.0%), vascular access insufficiency in 3 patients (5.0%), and leg ischemia in 1 patient (1.7%). A total of 57 stents were implanted. All patients were followed up at 1, 3, 6, and 12 months after the procedure and annually thereafter.

RESULTS

The technical success rate was 93.3%. All patients for whom technical success was obtained received stents. There were four technical failures, all of which were owing to the failure of crossing the wire in occluded lesions. There were no procedure-related deaths. There were two stroke events (3.4%) and one embolic event (1.7%). Primary patency rates were 94.9, 90.8, and 85.8% at 1, 3, and 5 years, respectively.

CONCLUSIONS

EVT for SCA disease is an effective treatment with regard to initial success rate, clinical efficacy, and long-term primary patency. This minimally invasive procedure is appropriate as the treatment of first choice for proximal subclavian arterial obstructive disease.

Sudden cardiac arrest with acute myocardial infarction induced by left subclavian artery occlusion in a patient with prior coronary artery bypass surgery

Multivascular preventive and therapeutic approaches are necessary in patients with coronary artery disease because atherosclerosis has a common systemic pathogenesis. We present a rare case of sudden cardiac arrest with acute myocardial infarction induced by the total occlusion of left subclavian artery (LSCA) in a patient with a history of previous coronary artery bypass surgery using the left internal mammary artery. We initially performed blind-puncture of left brachial artery, attempting percutaneous coronary intervention because pulses were absent in both upper and lower extremities. However, the cause of sudden cardiac arrest was atherosclerotic total occlusion of LSCA. The patient was stabilized after successful revascularization of LSCA by percutaneous transluminal angioplasty with stent insertion.

Angioplasty versus stenting for subclavian artery stenosis

BACKGROUND

There is insufficient evidence to guide stent usage following angioplasty in subclavian artery stenosis.

OBJECTIVES

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

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched August 2011) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3). In addition, the authors searched the MEDLINE, EMBASE and LILACS databases, and handsearched relevant journals. Informal enquiries were made with the major stent device manufacturers to obtain information on unpublished data and any ongoing trials. There was no restriction on language.

SELECTION CRITERIA

Randomized controlled trials of endovascular treatment of subclavian artery lesions comparing angioplasty alone and stent implantation.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, the third author was asked to assess the study for inclusion.

MAIN RESULTS

To date we have not identified any completed or ongoing randomized controlled trials comparing 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.

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.

Prevalence and impact of the subclavian steal syndrome

OBJECTIVE

To determine the prevalence and impact of subclavian steal syndrome (SSS) in patients undergoing assessment of the carotid arteries.

SUMMARY BACKGROUND DATA

Vertebral artery flow reversal is often found among patients undergoing imaging of the extracranial vessels; however, there are no large studies evaluating the prevalence and natural history of SSS in stratified patients.

METHODS

Patients presenting for duplex ultrasound of the carotid arteries underwent 2 sets of bilateral arm pressure measurements. Patients with a pressure differential (PD) >20 mm Hg were examined in detail for vascular obstruction ipsilateral to the affected arm. When appropriate, computer tomographic angiography (CTA), magnetic resonance angiography, and angiography were performed. Signs and symptoms related to SSS and the types of interventions performed were recorded.

RESULTS

In a period of 6 years, 7881 carotid duplex scans were performed, with a PD >20 mm Hg in 514 (6.5%) patients and a left arm preponderance (82%). SSS was complete in 61%, partial in 23%, and absent in 16%. Symptoms were present in 38 patients with 32 experiencing symptoms of the posterior circulation, 4 of arm ischemia, and 2 of cardiac ischemia. Symptoms occurred more frequently as the arm PD increased. Of the 38 symptomatic patients, only 7 underwent an intervention (2 with subclavian-carotid bypass and 5 with percutaneous transluminal angioplasty stenting of the subclavian).

CONCLUSIONS

SSS is a frequent finding in patients undergoing carotid duplex scanning. Patients are commonly asymptomatic and rarely require an intervention. A significantly elevated arm PD (>40-50 mm Hg) is more commonly associated with symptoms, complete steal, and the need for intervention.

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.