Results of a hybrid procedure for patients with proximal left subclavian artery stenosis and coronary artery disease

Subclavian Artery Calcification: A Narrative Review

Subclavian artery calcification (SAC) affects 2% of the population and presents a serious risk of developing into subclavian steal syndrome (SSS). Risk factors for plaque formation of the subclavian artery include diabetes, hypertension, and smoking. While SAC generally presents as asymptomatic, symptoms in severe cases may include numbness, pain at rest, and ischemic gangrene. Patients with severe SSS are at high risk of developing neurological symptoms as a result of vertebrobasilar insufficiency affecting posterior cerebral perfusion. On physical examination, SSS is preliminarily diagnosed from bilateral inter-arm systolic blood pressure discrepancy (>10 mmHg), which can be further confirmed with vascular imaging. Duplex ultrasound (DUS) is a cost-effective and non-invasive baseline technique for visualizing luminal stenosis and quantifying peak systolic velocity (PSV). Computed tomography angiography (CTA) provides high-quality, fast, three-dimensional (3D) imaging at the cost of introducing nephrotoxic contrast agents. Magnetic resonance angiography (MRA) is the safest 3D imaging modality, without the use of X-rays and contrast agents, that is useful in assessing plaque characteristics and degree of stenosis. DUS-assisted digital subtraction angiography (DSA) remains the gold standard for grading the degree of stenosis in the subclavian artery and determining the distance between the puncture site and lesion, which can be carried out in a combined procedure with endovascular management strategies. The fundamental treatment options are surgical and endovascular intervention. Endovascular treatment options include percutaneous transluminal angiography (PTA) for recanalization of the stenosed vessel and permanent balloon stenting to prevent collapse after PTA. Overall, the benefits of endovascular management encompass faster recovery, lower stenosis recurrence rate, and lower incidence of complications, making it the treatment of choice in low-risk patients. Surgical interventions, although more complex, are considered gold-standard treatment options.

Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease

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.