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El Bhali H, Bounssir A, Bakkali T, Jdar A, El Khloufi S, Lekehal B. Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review. Int J Surg Case Rep 2021; 85:106173. [PMID: 34284339 PMCID: PMC8318908 DOI: 10.1016/j.ijscr.2021.106173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 11/18/2022] Open
Abstract
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. SSS is caused by the reversal of blood flow in the vertebral artery. Doppler ultrasound is the ultimate screening tool for diagnosis. Treatment of symptomatic SSS is always indicated. Endovascular approach is the first-line treatment.
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Affiliation(s)
- Hajar El Bhali
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco.
| | - Ayoub Bounssir
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco
| | - Tarik Bakkali
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco
| | - Asmae Jdar
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco
| | - Samir El Khloufi
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco
| | - Brahim Lekehal
- Mohammed V University of Rabat, Morocco; Vascular Surgery Department, Ibn Sina University Hospital, 10104, Souissi, Rabat, Morocco
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Usai MV, Bosiers MJ, Bisdas T, Torsello G, Beropoulis E, Kasprzak B, Stachmann A, Stavroulakis K. Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:53-59. [PMID: 29786405 DOI: 10.23736/s0021-9509.18.10144-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endovascular treatment offers an alternative, less invasive approach to open repair for subclavian artery atherosclerotic disease (SAAD). However, only few studies compared the outcomes of both strategies in the long run. This study reports on the performance of endovascular and surgical revascularization for SAAD. METHODS A retrospective review was conducted on patients treated for SAAD at two institutions between January 1998 and December 2015. Primary outcome of this study was the composite endpoint of reintervention-free survival (RFS) defined as time to reintervention and/or death from any cause. Secondary endpoints included primary patency (PPR) and secondary patency (SPR) rates as well as overall survival and time to reintervention. RESULTS Surgical treatment was the preferred treatment option in 27 (25%) patients, while 83 (75%) patients underwent primary stent therapy. The median follow-up was 87 months (interquartile range [IQR]: 38 to 151) in the surgical group and 27 (IQR: 12 to 59) in the endovascular (P=0.0001). Severe arterial wall calcification was more commonly observed in the surgical arm (P<0.0001), while mild and moderate calcification in the endovascular (P=0.0004 and P=0.014). Vessel occlusion was more frequent among patients treated surgically (100% vs. 34%, P<0.0001). At 98 months RFS was significantly higher after surgical treatment (95% vs. 54%, HR: 8.4, 95% CI: 3.9 to 18.1, P=0.0002). Although overall survival did not differ significantly between the two groups (HR: 4.28, 95% CI: 0.86 to 21.22, P=0.093), open repair was associated with reduced reintervention rate (HR: 12.04, 95% CI: 4.98 to 29.12, P=0.001). The PPR at 98 months following surgical and endovascular therapy amounted to 96% and 65% (HR: 12.87, 95% CI: 5.44 to 30.44, P=0.0008) respectively. No significant difference was observed regarding the SPR between the two groups (100% vs. 95%, P=0.090). CONCLUSIONS Surgical treatment was associated in this cohort with increased patency and a significant reduction of reinterventions compared to the endovascular approach.
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Affiliation(s)
- Marco V Usai
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany - .,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany -
| | - Michel J Bosiers
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Theodosios Bisdas
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Efthymis Beropoulis
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Bernd Kasprzak
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Arne Stachmann
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
| | - Konstantinos Stavroulakis
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Münster, Germany.,Department of Vascular Surgery and Endovascular Surgery, University Clinic of Münster, Münster, Germany
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Akif Cakar M, Tatli E, Tokatli A, Kilic H, Gunduz H, Akdemir R. Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery. Singapore Med J 2018; 59:534-538. [PMID: 29546434 DOI: 10.11622/smedj.2018023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Mehmet Akif Cakar
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Ersan Tatli
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Alptug Tokatli
- Department of Cardiology, Golcuk Military Hospital, Kocaeli, Turkey
| | - Harun Kilic
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Huseyin Gunduz
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Ramazan Akdemir
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
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Cua B, Mamdani N, Halpin D, Jhamnani S, Jayasuriya S, Mena-Hurtado C. Review of coronary subclavian steal syndrome. J Cardiol 2017; 70:432-437. [PMID: 28416323 DOI: 10.1016/j.jjcc.2017.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/01/2017] [Accepted: 02/17/2017] [Indexed: 11/25/2022]
Abstract
The clinical benefits of using the left internal mammary artery (LIMA) to bypass the left anterior descending artery are well established making it the most frequently used conduit for coronary artery bypass surgery (CABG). Coronary subclavian steal syndrome (CSSS) occurs during left arm exertion when (1) the LIMA is used during bypass surgery and (2) there is a high grade (≥75%) left subclavian artery stenosis or occlusion proximal to the ostia of the LIMA resulting in "stealing" of the myocardial blood supply via retrograde flow up the LIMA graft to maintain left upper extremity perfusion. Although CSSS was once thought to be a rare phenomenon, its prevalence has been underestimated and is becoming increasingly recognized as a serious threat to the success of CABG. Current guidelines are lacking on recommendations for screening of subclavian artery stenosis (SAS) pre- and post-CABG. We hope to provide an algorithm for SAS screening to prevent CSSS in internal mammary artery bypass recipients and review treatment options in the percutaneous era.
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Affiliation(s)
- Bennett Cua
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Natasha Mamdani
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Halpin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sunny Jhamnani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sasanka Jayasuriya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Abstract
The supra-aortic arteries are no stranger to endovascular interventions. Since the 1980s, interventionists have been evaluating and refining the use of transluminal techniques for recanalizing stenotic and occlusive lesions in these large-bore, high-flow vessels. The authors present their methodologies for evaluating, selecting, and treating supra-aortic lesions with balloon angioplasty and stenting. Helpful suggestions are offered for optimizing the outcome of these endovascular approaches to atherosclerotic occlusive disease in the supra-aortic trunks.
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Affiliation(s)
- Frank J. Criado
- Division of Vascular Surgery, The Union Memorial Hospital, Baltimore, Maryland, USA
| | - Mordechai Twena
- Division of Vascular Surgery, The Union Memorial Hospital, Baltimore, Maryland, USA
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AbuRahma AF, Bates MC, Stone PA, Dyer B, Armistead L, Dean LS, Lavigne PS. Angioplasty and Stenting versus Carotid-Subclavian Bypass for the Treatment of Isolated Subclavian Artery Disease. J Endovasc Ther 2016; 14:698-704. [PMID: 17924737 DOI: 10.1177/152660280701400515] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ali F. AbuRahma
- Department of Surgery, Vascular Laboratory, and Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, West Virginia, USA
| | - Mark C. Bates
- Department of Surgery, Vascular Laboratory, and Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, West Virginia, USA
| | - Patrick A. Stone
- Department of Surgery, Vascular Laboratory, and Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, West Virginia, USA
| | - Benjamin Dyer
- Department of Surgery, Vascular Laboratory, and Vascular Center of Excellence, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, West Virginia, USA
| | | | - L. Scott Dean
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia, USA
| | - P. Scott Lavigne
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia, USA
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Henry M, Amor M, Henry I, Ethevenot G, Tzvetanov K, Chati Z. Percutaneous Transluminal Angioplasty of the Subclavian Arteries. J Endovasc Ther 2016. [DOI: 10.1177/152660289900600106] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To review the feasibility, risks, and long-term results of subclavian artery angioplasty with and without Palmaz stent placement. Methods: Over a 9-year period, 113 patients (67 males; mean age 63 ± 13 years) underwent percutaneous balloon angioplasty of subclavian occlusive lesions for a variety of indications: vertebrobasilar insufficiency (n = 70), upper limb ischemia (n = 50), coronary steal syndrome (n = 6), or anticipated coronary artery bypass grafting using the internal mammary artery in 12 asymptomatic patients. There were 94 (83%) stenoses and 19 (17%) occlusions with a mean percent stenosis of 80.1% ± 7.4% (range 70 to 100). Mean lesion length was 24 ± 8 mm (range 10 to 50). Beginning in 1989, stents were implanted for suboptimal dilation; in 1995, stenting became routine. Results: Overall, 103 (91%) of 113 lesions were successfully treated; 10 (53%) occlusions could not be recanalized. Fifty-one stents were implanted in 46 patients. There were 3 (2.6%) procedural complications: a transient ischemic attack, one major (fatal) stroke, and an arterial thrombosis 24 hours after the procedure (treated medically) (0.9% major stroke and death rate). During a mean 4.3-year follow-up (range to 10), 16 (15.5%) restenoses were treated with angioplasty (n = 4), stenting (n = 7), or surgery (n = 5). Primary and secondary patencies for all treated lesions (n = 113) at 8 years were 75% and 81%, respectively; in patients without initial stent placement, the rates were 69% and 76%, while in those with stents, the rates rose slightly to 87% and 94% at 2.5 years (NS). Patency rates for all 103 recanalized lesions were 83% and 90% at 8 years (81% and 90% without stent and 87% and 94% with stent at 2.5 years, respectively [NS]). Conclusions: Balloon angioplasty with or without stenting is safe and effective for treating subclavian artery occlusive diseases with good long-term patency. Recanalization of occlusions is more difficult to achieve. Stents (implanted only for suboptimal dilation) do not seem to improve long-term patency.
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Affiliation(s)
- Michel Henry
- Polyclinique Essey-les-Nancy, UCCI, Essey-les-Nancy, France
| | - Max Amor
- Polyclinique Essey-les-Nancy, UCCI, Essey-les-Nancy, France
| | - Isabelle Henry
- Polyclinique Essey-les-Nancy, UCCI, Essey-les-Nancy, France
| | | | | | - Zukaï Chati
- Polyclinique Essey-les-Nancy, UCCI, Essey-les-Nancy, France
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Komatsubara I, Kondo J, Akiyama M, Takeuchi H, Nogami K, Usui S, Hirohata S, Kusachi S. Subclavian steal syndrome: a case report and review of advances in diagnostic and treatment approaches. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2016; 17:54-8. [DOI: 10.1016/j.carrev.2015.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/10/2015] [Accepted: 11/11/2015] [Indexed: 11/26/2022]
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Open Reconstructions for Symptomatic Atherosclerotic Lesions of the Supra-aortic Vessels: Thirty Years Results from Two University Hospitals. Ann Vasc Surg 2015; 29:404-10. [DOI: 10.1016/j.avsg.2014.09.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 09/01/2014] [Accepted: 09/12/2014] [Indexed: 11/22/2022]
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10
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Management of atherosclerotic supraaortic lesions. Eur Surg 2014. [DOI: 10.1007/s10353-014-0268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mufty H, Janssen A, Schepers S. Dealing with symptomatic stenosis of the subclavian artery: Open or endovascular approach? A case report. Int J Surg Case Rep 2014; 5:441-3. [PMID: 24973522 PMCID: PMC4147573 DOI: 10.1016/j.ijscr.2014.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/06/2014] [Accepted: 04/30/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Stenosis of the subclavian artery is uncommon and it rarely causes symptoms. Only symptomatic patients should be treated. PRESENTATION OF CASE We report a case of chronic left upper limb ischemia caused by subclavian artery stenosis after repetitive clavicular fixation. The stenosis was first treated with carotid-subclavian bypass and soon followed by angioplasty and stenting of the subclavian artery because of occlusion of the bypass. Finally, failure of these procedures necessitated a subclavian-axillary crossover bypass. DISCUSSION Both extra-anatomic bypass and percutaneous transluminal angioplasty are safe and effective. If feasible, many authors use endovascular treatment. According to literature, extra-anatomic bypass still remains the first choice of treatment for symptomatic patients. However, the introduction of routine stent implantation is equalling these results. Because of its lower long-term patency rate, endovascular treatment is favorable for patients at high risk. CONCLUSION Our case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis.
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Affiliation(s)
- Hozan Mufty
- Department of Vascular Surgery, AZ Damiaan, Ostend, Belgium.
| | | | - Stijn Schepers
- Department of Vascular Surgery, AZ Damiaan, Ostend, Belgium
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Stone PA, Srivastiva M, Campbell JE, Mousa AY. Diagnosis and treatment of subclavian artery occlusive disease. Expert Rev Cardiovasc Ther 2014; 8:1275-82. [DOI: 10.1586/erc.10.111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Mechanical thrombectomy in proximal subclavian artery in-stent occlusion. Cardiovasc Interv Ther 2013; 29:140-5. [PMID: 23943249 DOI: 10.1007/s12928-013-0199-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Mechanical thrombectomy is an established tool for endovascular therapy of acute/chronic in-stent occlusions of the lower extremities, especially for the superficial femoral artery. The authors report the use of the Rotarex catheter system for an in-stent proximal subclavian occlusion. CASE PRESENTATION A 51-year-old female patient with previous multiple attempts at left subclavian revascularization; primary endovascular stenting at the origin of the subclavian artery occluded at 3 months, and a carotid-subclavian bypass was placed distally to the stent. After 6 months from the first treatment, the patient was readmitted with an acute left arm ischemia and full occlusion of the bypass was confirmed at computed tomography angiography. An anterograde thrombectomy for in-stent restenosis, together with PTA with a drug-eluting balloon was performed in the subclavian artery with confirmed patency at 6 months. CONCLUSION Mechanical thrombectomy together with drug-eluting balloon PTA for in-stent occlusion or restenosis of the subclavian artery could be a promising procedure with a lower invasivity and risk with respect to surgical options.
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Osiro S, Zurada A, Gielecki J, Shoja MM, Tubbs RS, Loukas M. A review of subclavian steal syndrome with clinical correlation. Med Sci Monit 2012; 18:RA57-63. [PMID: 22534720 PMCID: PMC3560638 DOI: 10.12659/msm.882721] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 08/25/2011] [Indexed: 12/15/2022] Open
Abstract
Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.
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Affiliation(s)
- Stephen Osiro
- Department of Anatomical Sciences, School of Medicine, St. George’s University, Grenada, West Indies
| | - Anna Zurada
- Department of Anatomy, Medical School Varmia and Mazuria, Olsztyn, Poland
| | - Jerzy Gielecki
- Department of Anatomy, Medical School Varmia and Mazuria, Olsztyn, Poland
| | | | - R. Shane Tubbs
- Pediatric Neurosurgery, Children’s Hospital, Birmingham, AL. U.S.A
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine, St. George’s University, Grenada, West Indies
- Department of Anatomy, Medical School Varmia and Mazuria, Olsztyn, Poland
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Song L, Zhang J, Li J, Gu Y, Yu H, Chen B, Guo L, Wang Z. Endovascular Stenting vs. Extrathoracic Surgical Bypass for Symptomatic Subclavian Steal Syndrome. J Endovasc Ther 2012; 19:44-51. [DOI: 10.1583/11-3692.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
Endovascular treatment of supra-aortic atherosclerotic arterial stenoses and occlusions using percutaneous transluminal angioplasty (PTA) and stent placement is an accepted first-choice procedure. Technical success, primary success, and midterm patency after PTA and stent placement for the treatment of stenosed or obstructed brachiocephalic arteries are promising and complication rates are low. Permanent miniaturization and device improvement makes treatment of atherosclerotic obstructive disease by endovascular means in brachial and cephalic arteries a safe procedure showing promising midterm patency rates.
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Affiliation(s)
- S Müller-Hülsbeck
- Department of Radiology, University Hospitals Schleswig-Holstein-Campus Kiel, Kiel, Germany
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17
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Aiello F, Morrissey NJ. Open and Endovascular Management of Subclavian and Innominate Arterial Pathology. Semin Vasc Surg 2011; 24:31-5. [DOI: 10.1053/j.semvascsurg.2011.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Interventional Neuroradiologic Therapy of Atherosclerotic Disease and Vascular Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10061-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
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.
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Sixt S, Rastan A, Schwarzwälder U, Bürgelin K, Noory E, Schwarz T, Beschorner U, Frank U, Müller C, Hauk M, Leppanen O, Hauswald K, Brantner R, Nazary T, Neumann FJ, Zeller T. Results after balloon angioplasty or stenting of atherosclerotic subclavian artery obstruction. Catheter Cardiovasc Interv 2009; 73:395-403. [DOI: 10.1002/ccd.21836] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Linni K, Ugurluoglu A, Mader N, Hitzl W, Magometschnigg H, Hölzenbein T. Traitement endovasculaire versus chirurgie pour lésions proximales de l'artère sous-clavière. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.acvfr.2009.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Linni K, Ugurluoglu A, Mader N, Hitzl W, Magometschnigg H, Hölzenbein TJ. Endovascular management versus surgery for proximal subclavian artery lesions. Ann Vasc Surg 2008; 22:769-75. [PMID: 18809284 DOI: 10.1016/j.avsg.2008.08.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 07/14/2008] [Accepted: 08/05/2008] [Indexed: 11/28/2022]
Abstract
Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.
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Affiliation(s)
- K Linni
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria.
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Subclavian artery revascularization: an outcome analysis based on mode of therapy and presenting symptoms. Ann Vasc Surg 2008; 22:70-8. [PMID: 18083331 DOI: 10.1016/j.avsg.2007.07.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 07/23/2007] [Indexed: 11/23/2022]
Abstract
Therapy for atherosclerotic occlusive subclavian arterial disease is undergoing a paradigm shift from open to endoluminal therapy. The aim of this study was to review the changing patterns of presentation and clinical outcomes based on presenting symptoms of subclavian artery revascularization. We performed a retrospective analysis of consecutive patients treated for symptomatic atherosclerotic occlusive subclavian arterial disease from 1992 through 2006. Mean follow-up was 4 years. One hundred fourteen patients with a mean age of 63 years (range 33-89, 61% female) underwent 137 procedures. Of these, 89% had hypertension, 32% were diabetic, 69% had hyperlipidemia, and 13% had chronic renal insufficiency. Sixty-seven primary stent attempts (five technical failures) and 70 open (64 carotid-subclavian bypasses, six subclavian-carotid transpositions) were performed. No deaths occurred within the 30-day perioperative period. Fifty-seven percent of the patients presented with symptoms of arm ischemia: exertional pain (84%), rest pain (12%), and ulceration (4%). The assisted primary patency was 81 +/- 7% and 80 +/- 10% at 5 and 10 years, respectively. Symptoms resolved in all patients, and none required major or minor amputations. Freedom from recurrent arm symptoms was 71 +/- 8% and 71 +/- 10% at 5 and 10 years, respectively. Twenty-five percent of the patients presented with a cardiac indication: preparation for a left internal mammary artery (IMA) bypass in 61% and recurrent cardiac ischemia in the remainder. The assisted primary patency was 97 +/- 6% at 5 years. No IMAs were abandoned in this group, and the freedom from recurrent cardiac symptoms related to IMA distribution was 79 +/- 10% at 5 years. Eighteen percent of patients presented with posterior circulation symptoms secondary to vertebrobasilar disease. The assisted primary patency was 100 +/- 0% and 100 +/- 0% at 5 and 10 years, respectively. Freedom from recurrent vertebrobasilar symptoms was 95 +/- 6% and 95 +/- 10% at 5 and 10 years, respectively. Subclavian artery revascularization is safe and effective, but long-term outcomes are determined by the presenting symptomatology.
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AbuRahma AF, Bates MC, Stone PA, Dyer B, Armistead L, Dean LS, Lavigne PS. Angioplasty and Stenting Versus Carotid-Subclavian Bypass for the Treatment of Isolated Subclavian Artery Disease. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[698:aasvcb]2.0.co;2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Müller-Hülsbeck S, Both M, Charalambous N, Schäfer PJ, Heller M, Jahnke T. Endovaskuläre Behandlung arteriosklerotisch bedingter arterieller Stenosen und Okklusionen der Aortenbogengefäße: Mittelfristige Ergebnisse einer Ein-Center-Analyse. ACTA ACUST UNITED AC 2007; 56:119-28. [PMID: 17390951 DOI: 10.1016/j.rontge.2006.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine mid-term patency rates after endovascular treatment of supraaortic atherosclerotic arterial stenoses and occlusions using percutaneous transluminal angioplasty (PTA) and stent placement. PATIENTS AND METHODS During a period of 83 months, 48 patients (18 female, 30 male; mean age 61 years, range 31-82 years) were included into this prospective single-center study. Fifty-five lesions of the brachial and cephalic arteries (subclavian/axillary artery n = 42, innominate artery n = 7, origin common carotid artery n = 6) were treated using PTA (n = 38), PTA plus stent (n = 11) or primary stent placement (n = 6). For anticoagulation, patients received a bolus of heparin (5000 IU) intraarterially during the intervention followed by intravenous application for 24h. At discharge, life-time application of ASA (100mg/day) was initiated. Follow-up protocol included clinical examination, colour-coded duplex ultrasound and intraarterial angiography in case of re-stenosis. RESULTS PTA and stent placement were technically successful in all patients (100%). No major complications occurred. Of seven patients presenting with total occlusions, six were treated with stent placement. Stent implantation was also performed in all lesions located at the origin of the supraaortic arteries (n = 6). In 38 lesions, the result of PTA was satisfactory. Mean follow-up time is 22 months (range 1-83 months). During follow-up examinations, re-stenoses occurred in 10 cases (at 1 month n = 2, at 6 months n = 2, at 12 months n = 3, at 24 months n = 3). In 9 lesions, re-interventions were performed (PTA n = 7; PTA plus stent n = 2). According to Kaplan-Meier life-table analysis, cumulative primary and primary assisted patency rates are 69.5% (patients at risk n = 15; standard error 9%) and 90.6% (patients at risk n = 16; standard error 6.3%) at 20 months, respectively. CONCLUSIONS Endovascular treatment of atherosclerotic obstructive disease in brachial and cephalic arteries is a safe procedure showing promising mid-term patency rates.
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Affiliation(s)
- Stefan Müller-Hülsbeck
- Universitätsklinikum Schleswig-Holstein--Campus Kiel, Klinik für Diagnostische Radiologie, Arnold-Heller-Strasse 9, 24105 Kiel, Germany.
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Marquardt F, Hammel D, Engel HJ, Hachmöller R, Luska G. The coronary-subclavian-vertebral steal syndrome (CSVSS). Clin Res Cardiol 2006; 95:48-53. [PMID: 16598445 DOI: 10.1007/s00392-006-0312-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2005] [Accepted: 08/17/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or-in addition with cerebral symptoms-in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS). METHOD We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks. RESULTS A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case. Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery. CONCLUSION The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.
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Affiliation(s)
- F Marquardt
- Abteilung für Thorax-Herz-Gefässchirurgie, Klinikum "Links der Weser" Bremen, Senator Wesslingstrasse 1, 28277 Bremen, Germany.
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Gessner C, Güttler A, Hammerschmidt S, Pfeiffer D, Wirtz H. [Rare cause of pectangina after coronary artery surgery]. Internist (Berl) 2005; 46:913-6. [PMID: 15928940 DOI: 10.1007/s00108-005-1436-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The coronary subclavian-steal-syndrome is a rare cause for angina pectoris following A. mammaria interna bypass operation. A 72-year-old male patient presented with vertigo and angina pectoris. A three vessel coronary artery disease was known and coronary artery surgery with three aortocoronary bypasses had been performed a year prior to presentation. A difference in peripheral arterial pressure between the right (150/80 mmHg) and the left (125/75 mmHg) arm was noted at physical examination. Color Doppler sonography of the left vertebral arteria exhibited a retrograde flow suggesting a coronary subclavian-steal-syndrome. Angiography revealed a significant stenosis of the left arteria subclavia. The stenosis was successfully treated with percutaneous transluminal angioplasty and stent implantation.
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Affiliation(s)
- C Gessner
- Abteilung Pneumologie der Medizinischen Klinik und Poliklinik I, Universitätsklinikum Leipzig, Germany.
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Brountzos EN, Petersen B, Binkert C, Panagiotou I, Kaufman JA. Primary Stenting of Subclavian and Innominate Artery Occlusive Disease: A Single Center?s Experience. Cardiovasc Intervent Radiol 2004; 27:616-23. [PMID: 15578138 DOI: 10.1007/s00270-004-0218-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To review immediate and midterm results of primary stenting for innominate and subclavian artery occlusive lesions. METHODS Retrospective data were collected from 48 consecutive symptomatic patients (27 men and 21 women, median age 64 years) having 49 subclavian and innominate artery lesions treated with stenting. Of the patients 52% had concomitant ischemic heart disease, and 30% had carotid and/or vertebral artery disease. Indication for treatment was vertebrobasilar insufficiency (VBI) in 16.6% of the patients; upper limb ischemia (ULI) in 31.3%; VBI and ULI in 12.5%; transient ischemic attack in 16.7%; angina in 12.5% before or after left internal mammary artery-to-coronary artery bypass grafting; and leg claudication in 10.4% before or after axillofemoral bypass grafting. Balloon-expandable stents were used in 44 lesions and self-expandable stents in 5 lesions. In total, 53 stents were placed in 48 patients. RESULTS Technical success was 96%, and clinical success 94%. We encountered four complications (two puncture site hematomas, one distal hand embolization and one transient cerebral ischemia). Two patients died within 30 days from other causes, and seven patients were lost to follow-up. Mean follow-up time was 16.7 months (range 0.3 to 68.2). Five patients had recurrent lesions treated by surgical (n = 2) or endovascular (n = 3) means. Cumulative primary patency rate was 91.7% and 77% at 12 and 24 months, respectively. Cumulative secondary patency rate was 96.5% and 91.7% at 12 and 24 months, respectively. CONCLUSION Stenting of subclavian and innominate artery lesions resulted in immediate resolution of patients' symptoms with durable midterm effect and few complications in a larger patient group with serious comorbid conditions.
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Affiliation(s)
- E N Brountzos
- Dotter Interventional Institute, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Rd., L342, Portland, Oregon 97201-3098, USA.
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Modarai B, Ali T, Dourado R, Reidy JF, Taylor PR, Burnand KG. Comparison of extra-anatomic bypass grafting with angioplasty for atherosclerotic disease of the supra-aortic trunks. Br J Surg 2004; 91:1453-7. [PMID: 15386319 DOI: 10.1002/bjs.4751] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Symptomatic stenosis of the supra-aortic trunks (subclavian, innominate and common carotid arteries) can be treated by angioplasty/stenting or surgical bypass. The aim of this study was to compare the initial success and outcome of these two types of treatment.
Methods
A prospective database was used to collect information on the presentation, initial success, complications and outcome in 76 patients treated in a single centre between 1983 and 2003.
Results
Thirty-five surgical extra-anatomic bypasses were performed, 13 carotid to carotid, 14 carotid to subclavian, two carotid to axillary, three axillary to axillary, one subclavian to axillary and two subclavian to subclavian. One graft occluded after 19 years. No limbs were amputated and no patient had a stroke. The secondary patency rate was 97 per cent at a mean follow-up of 5 years. Forty-one angioplasties were attempted, 34 of the left subclavian, six of the right subclavian and one of the innominate artery. Angioplasty for six subclavian occlusions was unsuccessful. Twenty-seven of 33 arteries remained patent at a mean follow-up of 4 years after a successful endovascular procedure.
Conclusion
Extra-anatomic bypass for supra-aortic trunk disease has a better patency than angioplasty, with a comparable complication rate.
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Affiliation(s)
- B Modarai
- Department of Surgery, Guy's and St Thomas' Hospitals, London, UK
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Bates MC, Broce M, Lavigne PS, Stone P. Subclavian artery stenting: factors influencing long-term outcome. Catheter Cardiovasc Interv 2004; 61:5-11. [PMID: 14696151 DOI: 10.1002/ccd.10711] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study provides extended follow-up of a nonrandomized series of symptomatic patients who underwent subclavian stent-supported angioplasty (SSA) with emphasis on preprocedure factors that may have influenced outcome. The endpoints of mortality and restenosis were analyzed using backward stepwise logistic regression with the following clinical variables: coronary artery disease, hypertension, hyperlipidemia, smoking, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal insufficiency/failure, and hypothyroidism. Restenosis is reported based on prospective serial noninvasive studies and/or angiography. Mortality was evaluated by retrospective database review and inquiry to the State Department of Health and Human Services' statistical registry in patients who were lost to follow-up. Over a 9-year period (mean follow-up, 36.1 +/- 30.4 months; maximum observation, 109.5 months), 101 stents were placed in 91 consecutive patients (37 male, 54 female). The mean age at intervention was 62.03 +/- 9.3. The procedure was technically successful in 89 patients 97% (mean pre- and postoperative stenosis and pressure gradients were 90.2% +/- 9.4% vs. 3.7% +/- 6.6%, P < 0.001, and 59.9 +/- 35.2 vs. 0 mm Hg, P < 0.001, respectively), with 13 minor complications and no immediate major complications. One patient died of unrelated causes within 30 days. Per Kaplan-Meier method, for years 1 through 5, the rates of overall patency were 96%, 91%, 86%, 77%, and 72%; likewise, overall patient survival was 93%, 88%, 8%4, 81%, and 76%. No clear predictors for restenosis were discovered, although a trend toward higher recurrence was noted in women (18.5% in female vs. and 8.6% in male; P > 0.05), but the same were less likely to die during follow-up (P > 0.001). Also, the presence of hypothyroidism (P = 0.004) and increasing age (P = 0.068) were positively correlated with all-cause mortality. This study suggests that SSA is predictable, safe, and durable. The diagnosis of symptomatic subclavian disease is of prognostic importance, with age and male gender representing important predictors of all-cause long-term mortality. The strong association of increased mortality with hypothyroidism is difficult to discard and raises the question of a yet to be described thyroid steal phenomena.
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Affiliation(s)
- Mark C Bates
- Charleston Area Medical Center Health Education and Research Institute, Charleston, West Virginia, USA.
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Levy EI, Kim SH, Bendok BR, Boulos AS, Xavier AR, Yahia AM, Qureshi AI, Guterman LR, Hopkins LN. Interventional Neuroradiologic Therapy. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50087-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Sadato A, Satow T, Ishii A, Ohta T, Hashimoto N. Endovascular Recanalization of Subclavian Artery Occlusions. Neurol Med Chir (Tokyo) 2004; 44:447-53, discussion 454-5. [PMID: 15600279 DOI: 10.2176/nmc.44.447] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Percutaneous balloon angioplasty for subclavian stenosis achieves satisfactory procedural success rates except for total occlusion. Seven lesions in six consecutive patients who underwent stenting for subclavian total occlusion were reviewed to evaluate the feasibility and efficacy of endovascular stenting. Six lesions were treated using Palmaz stents, and one with the combination of a Palmaz and a SMART stent. Procedural success (residual stenosis < 30%) was achieved for all lesions. The only neurological complication was an embolism in a branch of the posterior cerebral artery, which resulted in homonymous hemianopsia. Follow-up angiography over 6 months after the stenting for five lesions found one in-stent re-occlusion and one ostial restenosis due to elastic recoil. No patient had any new or recurrent symptoms except for recurrent upper limb ischemia due to the case of in-stent re-occlusion during the clinical follow-up period of 1 to 52 months (mean 16.6 months). This complication was resolved by a second treatment. Our limited experience suggests that stenting can redilate even cases of angiographical total occlusion of the proximal segment of the subclavian artery.
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Affiliation(s)
- Akiyo Sadato
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto
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Wang H, Lanzino G, Fraser K, Tracy P, Wang D. Urgent endovascular treatment of acute symptomatic occlusion of the cervical internal carotid artery. J Neurosurg 2003; 99:972-7. [PMID: 14705723 DOI: 10.3171/jns.2003.99.6.0972] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The prognosis of patients with acute symptomatic cervical internal carotid artery (ICA) occlusion is generally considered to be poor. Traditionally, such patients are not considered eligible for urgent thrombolytic/endovascular treatment. Since 1998, an aggressive therapeutic approach with endovascular treatment has been adopted at the authors' institution. In this report they assess whether aggressive treatment of ICA occlusion is appropriate.
Methods. The clinical characteristics and outcome of six consecutive patients treated urgently with an endovascular approach between 1998 and 2001 are reviewed and summarized.
Recanalization was accomplished in all patients. At a mean follow-up period of 8 months (range 2–14 months), five of six patients had good or excellent outcomes (modified Rankin Scale [mRS] Score 0–1) and one had a poor outcome (mRS Score 4).
Conclusions. With recent advancements in thrombolytic and endovascular treatments, an aggressive endovascular approach in patients with acute symptomatic cervical ICA occlusion may be successful. Further clinical data are required to determine the optimal endovascular approach in these patients.
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Affiliation(s)
- Huan Wang
- Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine at Peoria, Illinois 61656, USA
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Bates MC, AbuRahma AF, Stone PA. Restenting for subclavian in-stent restenosis with symptomatic recurrent coronary-subclavian steal. J Endovasc Ther 2002; 9:676-9. [PMID: 12431153 DOI: 10.1177/152660280200900519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine whether restenting for recurrent coronary-subclavian syndrome is technically feasible, provides durable results, and is a reasonable alternative to surgery. CASE REPORT A 58-year-old woman with a left internal mammary artery (LIMA) bypass to the left anterior descending artery underwent angioplasty and stent placement for left subclavian stenosis and coronary-subclavian steal. Twenty-three months later, she returned with progressive angina and left arm claudication; heart catheterization demonstrated restenosis of the subclavian artery at the stent site with recurrence of the coronary-subclavian steal. Successful redo angioplasty and stenting resulted in normal antegrade flow through the LIMA graft. The patient has remained asymptomatic for 3 years without evidence of recurrent in-stent stenosis on serial noninvasive studies. CONCLUSIONS Restenting is technically feasible and appears to be a durable response to subclavian in-stent restenosis in patients with coronary subclavian steal.
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Affiliation(s)
- Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston, West Virginia, USA.
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Bates MC, AbuRahma AF, Stone PA. Restenting for Subclavian In-Stent Restenosis With Symptomatic Recurrent Coronary-Subclavian Steal. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0676:rfsisr>2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Uurto IT, Lautamatti V, Zeitlin R, Salenius JP. Long-term outcome of surgical revascularization of supraaortic vessels. World J Surg 2002; 26:1503-6. [PMID: 12297936 DOI: 10.1007/s00268-002-6443-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to evaluate long-term results of different surgical reconstructions of supraaortic vessels, particularly the subclavian and innominate arteries. It is a retrospective review of 33 years experience in a teaching hospital; 80 surgical revascularizations were performed in 76 patients who suffered occlusive disease of subclavian or innominate artery from 1965 to 1998. These included 38 bypass (BP) operations (28 carotid-subclavian, 4 aorto-subclavian, 3 aorto-innominate, and 3 subclavian transpositions) and 42 endarterectomies (EA). All available patients (34) were reassessed clinically, and by triplex scanning. The mean clinical follow-up was 9 months (range 1 to 116 months) for all patients and for control-examined patients 158 months (range 6 to 346 months). Four patients were lost to follow-up. The perioperative mortality was 2.5% (BP, 0%; EA, 5%). The overall patency rate for both the BP and the EA procedures was 95% at 1 and 5 years; 91% at 10 years (BP, 89%; EA, 93%) and 89% (BP, 87%; EA, 90%) at 15 years. Most of the patients (84%) were satisfied with the clinical result in the long term. We conclude that surgical revascularization of supraaortic vessels is an infrequent procedure, and all surgical techniques give good and durable long-term outcome.
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Affiliation(s)
- Ilkka T Uurto
- Department of Surgery, Tampere University Hospital and Tampere University School of Medicine, PO Box 2000, 33521 Tampere, Finland.
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Schillinger M, Haumer M, Schillinger S, Mlekusch W, Ahmadi R, Minar E. Outcome of Conservative Versus Interventional Treatment of Subclavian Artery Stenosis. J Endovasc Ther 2002. [DOI: 10.1583/1545-1550(2002)009<0139:oocvit>2.0.co;2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Schillinger M, Haumer M, Schillinger S, Mlekusch W, Ahmadi R, Minar E. Outcome of conservative versus interventional treatment of subclavian artery stenosis. J Endovasc Ther 2002; 9:139-46. [PMID: 12010091 DOI: 10.1177/152660280200900201] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare the outcome of conservative treatment versus percutaneous transluminal angioplasty (PTA) of subclavian artery stenosis in terms of long-term hemodynamic and symptomatic outcome in a retrospective, nonrandomized study. METHODS Within a 14-year period, 295 consecutive inpatients were treated for subclavian artery stenosis. Excluding 21 (7%) surgical cases, the remaining 274 patients were treated either conservatively (n = 165) or with PTA (n = 109). Medical history, physical findings, and sonographic and angiographic data were recorded from the medical records of the 223 (81%) patients who were followed until the year 2000; 166 patients were then reinvestigated with oscillography, Doppler measurements, and duplex sonography. Outcomes of conservative versus interventional therapy were analyzed based on the intention to treat principle. RESULTS After a median 42-month follow-up (interquartile range 18-85), patients treated with PTA had a 60% risk reduction for hemodynamic subclavian stenosis compared to conservative treatment (adjusted hazard ratio 0.4, 95% confidence interval 0.2-0.6, p<0.0001). However, the risk of having a symptomatic stenosis at the time of follow-up did not differ between the treatment groups (p=0.3). CONCLUSIONS Endovascular revascularization improves the long-term hemodynamic outcome in patients with subclavian stenosis, but many conservatively treated patients become asymptomatic during follow-up. Interventional treatment may be considered primarily for patients with severe symptoms of vertebrobasilar insufficiency, critical ischemia, or peripheral emboli.
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Affiliation(s)
- Martin Schillinger
- Department of Internal Medicine II, Division of Angiology, University of Vienna Medical School, Vienna, Austria.
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Redmond KC, Barry MC, Kavanagh E, Dundon S, O'Malley MK. Bilateral subclavian steal syndrome. Ir J Med Sci 2002; 171:44-5. [PMID: 11993596 DOI: 10.1007/bf03168943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Bilateral atherosclerotic subclavian artery occlusion is rare. AIM To describe the surgical treatment of a patient with symptomatic bilateral subclavian artery occlusion. METHODS A midline sternotomy and bilateral aorto-subclavian bypass was performed in a male with upper limb, exercise-induced vertigo. RESULTS Postoperatively symptomatic improvement paralleled an increase in brachial systolic arterial blood pressure readings. CONCLUSION Bypass grafting is the more durable option for subclavian artery occlusion, as angioplasty with or without stenting is associated with a higher rate of late stenosis.
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Affiliation(s)
- K C Redmond
- Department of Vascular Surgery, Mater Misericordiae Hospital, Dublin, Ireland
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Schillinger M, Haumer M, Schillinger S, Ahmadi R, Minar E. Risk Stratification for Subclavian Artery Angioplasty:Is There an Increased Rate of Restenosis After Stent Implantation? J Endovasc Ther 2001. [DOI: 10.1583/1545-1550(2001)008<0550:rsfsaa>2.0.co;2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Schillinger M, Haumer M, Schillinger S, Ahmadi R, Minar E. Risk stratification for subclavian artery angioplasty: is there an increased rate of restenosis after stent implantation? J Endovasc Ther 2001; 8:550-7. [PMID: 11797967 DOI: 10.1177/152660280100800603] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare long-term patency after balloon angioplasty of stenotic or occluded subclavian arteries with and without adjunctive stenting and to identify independent risk factors for restenosis after balloon angioplasty. METHODS In a retrospective cohort study, 115 consecutive patients (65 women; mean age 60 years, interquartile range 53-68) who underwent PTA for atherosclerotic subclavian artery obstruction within a 15-year period were included. Among these, 26 (23%) consecutive patients had Palmaz stents routinely implanted since 1996. Follow-up investigation was performed in the year 2000. Patency during the median 44-month follow-up period (interquartile range 18-69 months, minimum 12) was evaluated by oscillography, blood pressure measurement, and color-coded duplex sonography. The predictive value of possible risk factors for restenosis was assessed in a multivariate model controlling for cardiovascular comorbidities and angiographic data. RESULTS PTA success was achieved in 98 (85%) patients, 72 (81%) of 89 undergoing angioplasty alone and all 26 with stents. Complete occlusion of the vessel and long lesions (> or = 2 cm) correlated with a lower success rate. One-year patency was 76% in unstented arteries and 95% in stented lesions due to better primary technical success, but at 4 years, the patency rates were 59% in arteries with stents and 68% in arteries without. Long lesions, residual stenosis after PTA, and stent implantation were independent predictors for restenosis after successful intervention. CONCLUSIONS Subclavian arterial stent implantation is associated with better 1-year patency than PTA due to improved technical success, but intermediate and long-term outcomes are less favorable, as instent restenosis frequently occurs.
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Affiliation(s)
- M Schillinger
- Department of Internal Medicine II, University of Vienna Medical School, Austria.
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Lobato EB, Kern KB, Bauder-Heit J, Hughes L, Sulek CA. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2001; 15:689-92. [PMID: 11748514 DOI: 10.1053/jcan.2001.28309] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To identify the incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. DESIGN Prospective. SETTING Veterans Affairs Medical Center and university-affiliated medical center. PARTICIPANTS Adult patients with prior coronary artery bypass graft surgery and documented use of an internal mammary artery. INTERVENTIONS Bilateral simultaneous brachial blood pressures were determined noninvasively. The presumptive diagnosis of ipsilateral subclavian artery stenosis and coronary-subclavian steal syndrome was made if the systolic blood pressure differential was >20 mmHg. MEASUREMENTS AND MAIN RESULTS The presumptive diagnosis of ipsilateral subclavian artery stenosis based on a blood pressure differential was made in 6 of 86 (5%) patients screened. The diagnosis of coronary-subclavian steal syndrome was confirmed at cardiac catheterization by observing retrograde internal mammary artery flow in 3 patients or lack of internal mammary artery flow in 1 patient (3.4%). All 4 patients with angiographic confirmation had either angina or silent ischemia. Three patients had successful carotid subclavian bypass, and 1 patient refused surgery. Two patients had no evidence of myocardial ischemia and underwent their planned procedure without incident. CONCLUSION Coronary-subclavian steal syndrome occurs with relative frequency in noncardiac surgery patients with prior coronary artery bypass graft surgery using internal mammary artery conduits. Bilateral blood pressure measurements should be routinely performed during the preoperative evaluation. A pressure differential >20 mmHg should suggest the possibility of coronary-subclavian steal syndrome.
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Affiliation(s)
- E B Lobato
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254, Gainesville, FL 32610-0254, USA.
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Gao Wang Z, Hua Wang S, Yu J, Ming Zhang X, Dong Wu J, Xin Li G. Iatrogenic Subclavian Steal Syndrome. Int J Angiol 2001; 10:24-26. [PMID: 11178782 DOI: 10.1007/bf01616339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
New complications are resulting from percutaneous transluminal angioplasty (PTA) and stent deployment. A 43-year-old female, admitted with weakness in the right arm, was diagnosed with right subclavian stenosis. Following PTA and a Palmaz stent deployment, her condition worsened, and symptoms spread. A corrective surgical procedure found the Palmaz stent to be almost completely compressed. The stent and plaques were carefully extracted. The etiology of compressed stent was probably due to an insufficient radial force or Hoop strength of stent. If an occlusion of the subclavian artery occurs at the segment proximal to the orifices of vertebral artery and internal mammary artery, a vertebral-subclavian steal syndrome may occur. This can be diagnosed in patients manifesting symptoms that include vertebral-basilar arterial insufficiency and a difference in brachial systolic blood pressure of at least 30 mm Hg between the two arms, with a bruit at the base of the neck or in the supraclavicular area. </hea
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Affiliation(s)
- Zhong Gao Wang
- China Vascular Institute, First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
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AbuRahma AF, Robinson PA, Jennings TG. Carotid-subclavian bypass grafting with polytetrafluoroethylene grafts for symptomatic subclavian artery stenosis or occlusion: a 20-year experience. J Vasc Surg 2000; 32:411-8; discussion 418-9. [PMID: 10957647 DOI: 10.1067/mva.2000.108644] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE Since the advent of subclavian artery percutaneous transluminal angioplasty/stenting, several authorities advocate it as the treatment of choice for patients with subclavian artery disease, claiming results equal to or better than those of reconstructive vascular surgery. However, most of their quoted surgical series included patients who may have other brachiocephalic disease who were treated nonuniformly by means of various bypass grafts with different grafts in the same series (eg, Dacron, polytetrafluoroethylene [PTFE], or vein). In this study, we analyze the long-term results of a large series of carotid-subclavian bypass grafts for subclavian artery disease in which PTFE was uniformly used; the study can be used as a future reference to compare the results of subclavian artery percutaneous transluminal angioplasty/stenting. PATIENT POPULATION AND METHODS Fifty-one patients with symptomatic subclavian artery disease (40 occlusions and 11 stenoses) who were treated with carotid-subclavian bypass grafts (PTFE [Goretex]) during a 20-year period were analyzed. Graft patency was determined clinically and confirmed with Doppler scanning pressures and duplex ultrasound scanning. The cumulative patency, overall survival, and symptom-free survival rates were calculated with the life table method. RESULTS Indications for surgery were arm ischemia in 34 patients (67%), vertebrobasilar insufficiency (VBI) in 27 (53%), and symptomatic subclavian steal in 7 (14%). A combination of arm ischemia and VBI occurred in 17 (33%) of these patients. The mean follow-up was 7.7 years with a median of 7.0 years (range, 1-19 years). The 30-day morbidity rate was 6%, with no perioperative stroke or mortality. Immediate relief of symptoms was achieved in 100% of patients; however, four patients (8%) had late recurrent symptoms (three with VBI). The primary patency and secondary patency rates at 1, 3, 5, and 10 years were 100%, 98%, 96%, and 92% and 100%, 98%, 98%, and 95%, respectively. The symptom-free survival rates at 1, 3, 5, and 10 years were 100%, 96%, 82%, and 47%, respectively. The overall survival rates at 1, 3, 5, and 10 years were 100%, 98%, 86%, and 57%. The mean hospital stay was 3.5 days in the late 70s and 80s and 2.1 days in the 90s (P <. 001). CONCLUSIONS Carotid-subclavian bypass grafts with PTFE grafts for subclavian artery disease are safe, effective, and durable and should remain the procedure of choice, particularly in good-risk patients.
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Affiliation(s)
- A F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston, WV 25304, USA.
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Perkins JM, Magee TR, Hands LJ, Collin J, Morris PJ. The long-term outcome after axillo-axillary bypass grafting for proximal subclavian artery disease. Eur J Vasc Endovasc Surg 2000; 19:52-5. [PMID: 10706835 DOI: 10.1053/ejvs.1999.0947] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to investigate the outcome of patients undergoing axillo-axillary bypass grafting for symptomatic subclavian artery stenoses or occlusions. DESIGN retrospective case-note review and prospective review of patients available for follow-up. PATIENTS AND METHODS sixteen patients had axillo-axillary grafts in a 17-year period. Ten patients were available for review and assessed clinically, by measurement of arm blood pressures, and by duplex scanning of their grafts. RESULTS one patient died and three grafts occluded within 30 days of operation. Nine out of 10 grafts scanned were patent, with three further grafts clinically patent at death. Overall secondary patency was 75% at a combined median follow-up of 56 months (range 12-204 months). Recurrent symptoms occurred in two patients, one with an occluded graft and one with a patent graft. CONCLUSION axillo-axillary bypass grafts give good long-term symptom-free results.
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Affiliation(s)
- J M Perkins
- Nuffield Department of Surgery, University of Oxford, The John Radcliffe, Oxford, UK
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Mingoli A, Sapienza P, Feldhaus RJ, Bartoli S, Palombi M, di Marzo L, Cavallaro A. Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience. J Vasc Surg 1999; 29:894-901. [PMID: 10231641 DOI: 10.1016/s0741-5214(99)70217-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. METHODS The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. RESULTS One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9. 8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 +/- 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. CONCLUSION The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions.
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Affiliation(s)
- A Mingoli
- First Department of Surgery, University of Rome "La Sapienza", Italy
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Rodriguez-Lopez JA, Werner A, Martinez R, Torruella LJ, Ray LI, Diethrich EB. Stenting for atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg 1999; 13:254-60. [PMID: 10347257 DOI: 10.1007/s100169900254] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to evaluate the results of stenting subclavian artery pathologic lesions. Between July 1991 and December 1995, 69 patients (36 males: mean age 67 years, range 34-87 years) underwent intraluminal balloon dilatations followed by stent implantations in 70 subclavian arteries to treat primary atherosclerotic stenoses > 70%. Twenty-three patients (34%) were treated for vertebrobasilar insufficiency (VBI), 25 patients (36%) were treated for upper limb ischemia (ULI), and 10 patients (15%) were treated for both VBI and ULI. Other indications included symptomatic subclavian steal phenomenon (SSS), protection of dialysis arteriovenous fistula, coronary steal syndrome, protection of axilloaxillary bypass, distal embolization, and protection of left internal mammary artery (LIMA)-coronary bypass. Fifty-three cases (78%) were treated for stenosis and 17 cases (22%) for total occlusion of the origin of the subclavian artery. The results of this series indicate that stenting of subclavian artery stenosis appears safe and feasible with good short and mid-term patency, improving at those intervals the initial disappointing reports of balloon angioplasty alone. However, its long-term durability is at present unknown.
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Affiliation(s)
- J A Rodriguez-Lopez
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, Phoenix 85006, USA
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Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999; 33:1238-45. [PMID: 10193722 DOI: 10.1016/s0735-1097(98)00690-1] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To compare stenting of aortic arch vessel obstruction with surgical therapy and to establish recommendations for treatment. BACKGROUND Though surgery has been considered to be the procedure of choice for subclavian and brachiocephalic obstruction, little work has been done to compare it with stenting. METHODS Eighteen patients with symptomatic aortic arch vessel stenosis or occlusion were treated with stenting, followed by periodic clinical follow-up and noninvasive arterial Doppler studies. Data were compared with the results as shown in a systematic review of a published series of surgery and stenting procedures which included comparison of technical success, complications, mortality and patency. RESULTS Primary success in our series was 100% with improvement in mean stenosis from 84+/-11% to 1+/-5% and mean arm systolic blood pressure difference from 44+/-16 mm Hg to 3+/-3 mm Hg. There were no major complications (death, stroke, TIA, stent thrombosis or myocardial infarction). At follow-up (mean 17 months), all patients were asymptomatic with 100% primary patency. Literature review demonstrates equivalent patency and complications in the other published series of stenting. In contrast, there was a similar patency but overall incidence of stroke of 3+/-4% and death of 2+/-2% in the published surgical series. CONCLUSIONS Subclavian or brachiocephalic artery obstruction can be effectively treated by primary stenting or surgery. Comparison of stenting and the surgical experience demonstrates equal effectiveness but fewer complications and suggests that stenting should be considered as first line therapy for subclavian or brachiocephalic obstruction.
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Affiliation(s)
- P Hadjipetrou
- Interventional Cardiovascular Medicine, Lahey Clinic, Medical Center, Burlington, Massachusetts 01805, USA
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