Percutaneous transluminal angioplasty for atherosclerotic stenosis of the subclavian or innominate artery: angiographic and clinical outcomes in 36 patients

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.

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.

Preliminary experience with new generation balloon expandable stent-graft in the treatment of innominate artery obstructive disease

BACKGROUND

The aim of this study was to describe a single center preliminary experience with the use of a specific balloon expandable stent-graft for the treatment of innominate artery (IA) obstructive lesions.

METHODS

We report our experience with four male patients treated with Gore Viabahn balloon (Gore Medical, Flagstaff, AZ, USA) expandable stent-graft for different types of IA stenosis: three patients were symptomatic for vertebrobasilar insufficiency, while one patient was asymptomatic for cerebrovascular symptoms. The stent grafts were deployed using retrograde (N.=2) or antegrade approach (N.=2), aiming to cover the entire lesions length and to slightly protrude into the aortic arch. Post-dilatation was performed with a compliant balloon. One patient presented a tandem lesion (IA and right internal carotid artery) and after the stenting of the IA he was treated also with a carotid artery stenting during the same procedure.

RESULTS

Technical success was achieved in all patients. No perioperative or postoperative complications had been reported and the neurological disorders disappeared for the three symptomatic patients. After a mean clinical and radiological follow-up of 24±5 months, all the stents were patent and perfectly adapted to the vessels.

CONCLUSIONS

This preliminary clinical experience shows that the use of the Gore Viabahn balloon (Gore Medical) expandable stent-graft seems safe and feasible for the treatment of the IA obstructive lesions, also in presence of irregular plaques and hostile anatomies for an endovascular treatment. Larger experiences and long-term data are mandatory.

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.

The Effects of Pro-Inflammatory and Anti-Inflammatory Agents for the Suppression of Intimal Hyperplasia: An Evidence-Based Review

Anti-atherogenic therapy is crucial in halting the progression of inflammation-induced intimal hyperplasia. The aim of this concise review was to methodically assess the recent findings of the different approaches, mainly on the recruitment of chemokines and/or cytokine and its effects in combating the intimal hyperplasia caused by various risk factors. Pubmed and Scopus databases were searched, followed by article selection based on pre-set inclusion and exclusion criteria. The combination of keywords used were monocyte chemoattractant protein-1 OR MCP-1 OR TNF-alpha OR TNF-α AND hyperplasia OR intimal hyperplasia OR neointimal hyperplasia AND in vitro. These keywords combination was incorporated in the study and had successfully identified 77 articles, with 22 articles were acquired from Pubmed, whereas 55 articles were obtained from Scopus. However, after title screening, only twelve articles meet the requirements of defined inclusion criteria. We classified the data into 4 different approaches, i.e., utilisation of natural product, genetic manipulation and protein inhibition, targeted drugs in clinical setting, and chemokine and cytokines induction. Most of the articles are working on genetic manipulation targeted on specific pathway to inhibit the pro-inflammatory factors expression. We also found that the utilisation of chemokine- and cytokine-related treatments are emerging throughout the years. However, there is no study utilising the combination of approaches that might give a better outcome in combating intimal hyperplasia. Hopefully, this concise review will provide an insight regarding the usage of different novel approaches in halting the progression of intimal hyperplasia, which serves as a key factor for the development of atherosclerosis in cardiovascular disease.

Subclavian steal syndrome treated by kissing stenting of the subclavian and vertebral arteries

The prevalence of subclavian artery (SA) stenosis is approximately 2%. The exact prevalence of extracranial vertebral artery (VA) stenosis is undetermined, with estimates ranging from 7% to 40%. Nearly 25% of ischaemic strokes involve the vertebrobasilar circulation, and arteriosclerotic disease and narrowing of the proximal VA may be the cause for up to one-fifth of these incidents. The bulk of SA stenoses occur proximally to the ostium of the VA. Vertebrobasilar ischaemia can be caused both by VA and SA stenosis. Surgical and endovascular approaches are potential treatment options for SA/VA stenosis. It has been demonstrated that endovascular intervention is considerably safer for this pathology, and with advances in device technology, angioplasty with stenting has become the preferred treatment option. We present the case of a 76-year-old man who presented with vertebrobasilar ischaemia from coexisting stenosis of the SA/VA which was treated by endovascular methods.

Total arch replacement as treatment for repeated cerebral infarctions due to unstable plaque simultaneously in the innominate artery and left subclavian artery: a case report

We report a case of total arch replacement in a patient who suffered repeated cerebral infarctions due to unstable plaque simultaneously in the innominate and left subclavian arteries.

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.

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.

Simultaneous Kissing Stenting: A Valuable Technique for Reconstructing the Stenotic Initial Segment of the Right Subclavian Artery

Atherosclerotic stenosis or occlusion often involves the subclavian artery. For lesions that are close to the orifice of the right subclavian artery, stenting of the right subclavian artery itself blocks the pathway from the innominate artery to the right carotid artery and causes problems in patients with multiple angiostenosis, especially involving the right carotid system. In this study, we report 2 cases using simultaneous kissing stenting (SKS) of the right subclavian artery and the right carotid artery to relieve right subclavian stenosis and maintain right carotid system patency. Standard stenting methods were used to perform SKS. Two self-expanding stents were implanted simultaneously into the initial segment of the right subclavian artery and the right carotid artery, forming a "Y" shape, with the overlap of the proximal segments in the innominate artery ≥5 mm. After SKS, the stenosed right subclavian artery was dilated, and the patency of the right carotid system was maintained. The symptoms of patients were relieved and the stents were intact at several months of follow-up. In conclusion, SKS of the right subclavian artery and the right carotid artery might be a safe and effective procedure when the stenotic or occlusive lesion in the initial segment of the right subclavian artery is close to the orifice, and lesions (or potential ones) exist in the right carotid system.

Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary Artery Bypass Grafting Due to Right Subclavian Artery Origin Stenosis

Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA). Subclavian artery (SA) stenosis proximal to the ITA graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right SA origin stenosis after CABG. A 64-year-old man with a history of CABG using the right ITA presented with exertional right arm claudication. Angiogram showed a CSS and retrograde blood flow in the right vertebral artery (VA) due to severe stenosis of the right SA origin. Endovascular treatment of the right SA stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the SA proximal to the origin of the right VA and ITA through the right brachial artery approach and distal filter protection of the right internal carotid artery (ICA) through the left femoral artery (FA) approach were performed. Endovascular stenting for SA stenosis from the right FA approach was performed under cardiac and cerebral protection by filter-protection of the ICA and balloon-protection of the VA and ITA. Successful treatment of SA severe stenosis was achieved with no complications.

Carotid axillary artery bypass: an option following failed open and percutaneous procedures

Percutaneous transluminal angioplasty and stenting is being employed with increasing frequency for stenosis involving the brachiocephalic circulation. However, the efficacy of these procedures is limited by intimal hyperplasia and subsequent re-stenosis. Long-term results for treating lesions of the subclavian or innominate artery have shown significant re-stenotic rate. Accordingly, carotid-subclavian bypass remains as an important procedure. Alternative methods may still be required, particularly after failure of open re-vascularization and percutaneous techniques. This report describes an underused technique that enables upper extremity revascularization following prior attempts at endovascular and standard open techniques.

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.