Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-Guiding Catheter for Subclavian Artery Total Occlusion

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.

Filter-type Protection Device Retrieval Interfered by Deployed Stent during Subclavian Artery Stenosis Treatment: Case Report and Complication Avoidance Recommendation

Endovascular treatment is a standard procedure for subclavian artery stenosis or obstruction. However, great care should be taken to avoid embolic complications to the vertebral artery, and several methods have previously been reported. Hence, as surgical procedures become increasingly complicated, unintended issues may arise during treatment. Here, the authors report a case where the filter-type protection device was caught in the stent because the patient moved during treatment, leading to open surgery to recover the filter-type protection device． A 78-year-old female suffering from a left subclavian steal syndrome underwent stenting due to subclavian artery stenosis. The stenotic lesion was approached via the transfemoral route, and a filter-type protection device was advanced to the vertebral artery via the transbrachial route to prevent embolic complications. As the procedure was performed under local anesthesia, the patient moved during stent deployment proximally to the left vertebral artery origin, and the stent unintentionally advanced distally, covering the vertebral artery and obstructing the retrieval catheter for the filter-type protection device to advance. Failed attempts in recovering the filter-type protection device required open surgery for retrieval. Fortunately, there was no postoperative neurological and radiographic complication, ameliorating her chief complaint． The retriever catheter for the protection device should be advanced beyond the vertebral artery orifice just proximal to the protection device before stenting to avoid such complications while also thoroughly considering the type of anesthesia during treatment．.

Transfemoral subclavian artery stenting through a shaped guiding catheter without pull-through technique: A case report

Transfemoral subclavian artery stenting can be challenging unless the placement of the guiding catheter is secured. Herein, we present a patient with subclavian artery stenosis treated with endovascular stenting using a shaped guiding catheter. A 79-year-old woman was admitted to our department because of a cold sensation and numbness of her left arm. Computed tomography revealed stenosis of the left subclavian artery (SA), located just proximal to the ostium of the left vertebral artery (VA). Doppler ultrasound showed reverse flow in the left VA. We planned to stent for the SA stenosis under the balloon protection of the left VA. The balloon protection device was easily navigated into the left VA through brachial access. After that, a self-expandable stent was successfully placed from just proximal to the VA origin to the ostium of the SA using a highly stable shaped guiding catheter. The patient recovered from the symptoms and was discharged 4 days after the procedure. The high stability of the shaped guiding catheter is advantageous during endovascular treatment of the subclavian artery.

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.

Combined Transradial and Transfemoral Approach Using a Compliant Balloon for Emboli Protection at the Vertebral Artery During Subclavian Stenosis Stenting: 2-Dimensional Operative Video

Endovascular intervention has become the mainstay of treatment for subclavian artery stenosis in many centers, with high technical success and low complication rates.1,2 However, potential embolization during proximal subclavian artery intervention can lead to catastrophic posterior circulation ischemic complications.3-5 Although considered a rare complication, the presence of a contralateral hypoplastic vertebral artery with persisting anterograde vertebral blood flow on the affected side is likely to increase the risk of embolization.3 The use of embolic protection devices, such as filters and noncompliant balloons, has been previously described.3,6,7 However, there is still a risk of distal embolization and vessel injury with the use of these devices.7 We present a technical video of a patient in their 80s with left subclavian stenosis who underwent subclavian stent-assisted percutaneous transluminal angioplasty (SAPTA) using an anterograde-retrograde access technique with a dual-lumen compliant balloon catheter (Scepter XC; MicroVention, Aliso Viejo, California) placed at the proximal segment of the left vertebral artery. With this approach, the compliant balloon provides adequate protection while minimizing the risk of endothelial injury and distal embolization. Written informed consent was obtained for the procedure. Patient consent was waived because all health information was deidentified.

Distal Embolic Protection by Manual Compression of the Vertebral Artery in Subclavian Artery Stenting

Objective

There is no established method for preventing vertebral artery embolization in percutaneous transluminal angioplasty (PTA) for subclavian artery stenosis. We manually compressed the supraclavicular fossa outside the sternocleidomastoid muscle to disrupt vertebral artery blood flow and prevent embolism. We report the usefulness of this procedure.

Case Presentations

Between April 2017 and July 2018, three patients with severe stenosis of the subclavian artery of 80% or higher were examined. For these patients, subclavian artery stenting was performed. The approach was via the left brachial artery in one patient and right femoral artery in two patients. After crossing the lesion, the vertebral artery was manually compressed and angiography confirmed that blood flow was blocked. In all patients, stent placement was successfully performed and good dilatation was confirmed by angiography. There were no neurological complications and no findings suggestive of acute cerebral infarction were found on magnetic resonance imaging (MRI).

Conclusion

Prevention of distal embolism by manual compression is simple, does not require multiple catheters, and is useful for subclavian artery stenting.

Combined Transradial and Transfemoral Approach With Ostial Vertebral Balloon Protection for the Treatment of Patients With Subclavian Steal Syndrome

Background: Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1–5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA.

Objective: To assess the safety and feasibility of a novel technique for distal embolic protection using balloon catheters during SA revascularization with a dual transfemoral and transradial access.

Methods: We describe a case series of patients with SSS who underwent SAPTA due to severe stenosis or occlusion of the SA using a combined anterograde/retrograde approach. Transfemoral access to SA was obtained using large bore guide sheaths. Ipsilateral transradial access was obtained using intermediate bore catheters. A Scepter XC balloon catheter was introduced through the transradial intermediate catheter into the ipsilateral VA at the ostium during SAPTA for distal embolic protection.

Results: A total of eight patients with SSS underwent subclavian SAPTA. Four patients had the combined anterograde/retrograde approach. Successful revascularization was achieved in three of them. It was difficult to create a channel in the fourth unsuccessful case due to heavily calcified plaque burden. No peri-operative ischemic events were identified. On follow-up, we demonstrated patency of the stents with resolution of symptoms and without any adverse events.

Conclusion: Subclavian stenting using a combined transradial and transfemoral access with compliant balloon catheters at the vertebral ostium for prevention of distal emboli may represent an alternative therapeutic approach for the treatment of SA stenosis and occlusions.