The treatment of focal aortic arch branch lesions with Palmaz stents

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

Introduction

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

Materials and methods

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

Results

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

Discussion

There are excellent screening tools and effective medical therapies which can be instituted if the SSS is diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness. Nevertheless, large, prospective, randomized and controlled trials are needed to compare the long-term patency rates between the endovascular and surgical techniques.

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

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Doppler ultrasound is the ultimate screening tool for diagnosis.

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Treatment of symptomatic SSS is always indicated.

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Endovascular approach is the first-line treatment.

Open Retrograde Stenting with a Sheathless Method Using a Balloon-guiding Catheter for Proximal Common Carotid Artery Stenosis

Objective

Carotid artery stenting (CAS) and carotid endarterectomy are relatively difficult for proximal common carotid artery (CCA) stenosis because of the difficulty in anatomical approach. We treated proximal CCA stenosis by retrograde stenting using a 9Fr Optimo for peripheral intervention with a sheathless method.

Case Presentation

A 60-year-old woman was scheduled for total arch replacement (TAR) for an aortic arch aneurysm. Preoperative cervical MRI incidentally revealed tandem stenosis in the left CCA. We intended to treat CCA stenosis prior to aortic arch replacement. Under general anesthesia, distal left CCA was exposed. A 9Fr Optimo was introduced into CCA by retrograde with a sheathless method. The retrograde CAS was performed under distal balloon protection. Her postoperative course was uneventful.

Conclusion

Retrograde stenting using a 9Fr Optimo for peripheral intervention with a sheathless method was safe and useful for proximal CCA stenosis.

Left subclavian artery stenosis treated with transcatheter stent placement in pediatric patients

Left subclavian artery (LSA) stenosis causing limb length shortening or vascular compromise or significant pulse volume and blood pressure differences between two upper limbs are rarely described in pediatric patients. Here, we are presenting three such cases, two of them were congenital and another one acquired in origin. All of them were successfully treated with transcatheter implantation of stent in LSA. Normalization of limb length was detected on follow-up.

Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting

Background

Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium.

Summary

To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions.

Key Message

In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.

Effectiveness of treatment of innominate artery stenosis with retrograde supra-aortic stent using a flow reversal stent system

We present the case of a 71-year-old man with critical stenosis of the innominate artery after previously undergoing bilateral carotid artery endarterectomies. We used an open retrograde approach of the right carotid artery to stent the innominate artery lesion employing the new ENROUTE Transcarotid Stent System with flow reversal.

The modified ‘no touch’ technique in the antegrade endovascular approach for left common carotid artery ostial stenosis stenting

Background

Open surgery and the retrograde endovascular approach via the distal left common carotid artery (LCCA) have some limitations in LCCA ostial stenosis treatment. The ‘no touch’ technique used in the renal artery was modified for this situation.

Methods

Fifteen selective LCCA stenosis patients were treated by the modified ‘no touch’ technique in the antegrade endovascular approach from March 2013 to March 2016. Thirteen underwent the transfemoral approach and the other two had the transbrachial approach due to a ‘bovine aortic arch’. Distal embolic protection devices were used in all cases. Follow-up included a neurological examination, carotid duplex scan, and office interview. Mean follow-up time was 18.2±11.5 months.

Results

The initial technical success rate was 100%. The average procedure time was 84.0±16.3 min. There were no procedure-related deaths. No clinical neurological complications occurred during the in-hospital stay. No incidence of death or major stroke occurred during the follow-up period; 6.7% (1/15) of patients had a contralateral minor stroke, 66.7% (4/6) of symptomatic patients were relieved of initial symptoms, and the rest showed improvement. No patient developed new ipsilateral neurological symptoms and no in-stent restenosis occurred during the follow-up period. These results were confirmed by ultrasound.

Conclusions

The modified ‘no touch’ antegrade endovascular technique is a feasible method for treating LCCA ostial lesions with a satisfactory initial success rate, acceptable procedure time, and comparable mid- and long-term results. This technique could be considered as a complementary option for LCCA ostial stenosis in addition to open surgery and the retrograde endovascular approach.

Innominate Artery Stenosis Presenting With Migratory Digital Ischemia

Background:

Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events.

Case Presentation:

An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits.

Conclusion:

Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.

Techniques for Endovascular Recanalization of Supra-Aortic Trunks

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.

Endovascular Management of Unusual Aneurysms of the Axillary and Subclavian Arteries

Purpose:

Aneurysms of the upper extremity arteries are uncommon and may be difficult to manage with standard surgical techniques. We report the exclusion of three axillary-subclavian aneurysms with covered stents.

Methods and Results:

Palmaz stents were covered with either polytetrafluoroethylene (2 cases) or brachial vein and deployed to exclude pseudoaneurysms in 1 axillary (ruptured) and 2 left subclavian arteries. Two of the patients had advanced cancer and died within 52 days and 3 months of treatment, but their aneurysms were occluded at the time of their death. The repair in the third patient is patent at 9 months.

Conclusions:

Endovascular exclusion of axillary and subclavian aneurysms with covered stents may offer a useful alternative to operative repair, particularly in patients with significant comorbidities.

A case of superior vena cava syndrome caused by a ruptured brachiocephalic artery aneurysm

An 84-year-old man was transferred to the emergency department for the treatment of shock. His upper body was swollen. Hematoma from the ruptured brachiocephalic artery aneurysm was compressing and obstructing the superior vena cava (SVC). A stent graft was deployed from the brachiocephalic artery to the right common carotid artery, and the proximal right subclavian artery was coil embolized. On postoperative day 5, when his neck swelling subsided and tracheal stenosis seemed resolved, the patient was extubated and the subsequent recovery was uneventful. He was discharged from the hospital on postoperative day 24. Although the stent grafting does not directly decompress the SVC by removing aneurysm and hematoma, it seems to be the treatment option for the morbid patients.

Thoracic mural thrombi: a case series and literature review

Thoracic mural thrombi (TMT) are rare but an important source of distal emboli. Treatment options are dynamic, ranging from open, endovascular to conservative therapies. We report two cases of TMT, one successfully treated with thoracic aortic endoluminal stent placement for visceral and peripheral embolization, the second treated conservatively for digital embolization secondary to TMT in the innominate artery.

New possibilities in the endovascular treatment of supraaortic vessels

Cerebrovascular disease, including stroke, represents the third-leading cause of death in Hungary and a leading cause of disability among the elderly population. The majority of all strokes are ischemic, mostly secondary to thromboembolic disease of the supraaortic vessels. We investigated new therapeutic methods in the endovascular treatment of these diseases. Surgical revascularization of supraaortic trunk stenosis is associated with high morbidity and mortality rates. Balloon angioplasty has become an increasingly accepted treatment of stenoocclusive supraaortic arterial disease. Natural history data and treatment guidelines do not exist for innominate and proximal common carotid artery lesions. We have confirmed in a large series of innominate artery angioplasties that it is a safe and effective procedure with an excellent initial success rate, with a lower complication rate than the surgical option and with a similar long-term patency rate as for surgery.

In the largest published study on transfemoral angioplasty of ostial and proximal common carotid artery stenosis we have proved that endovascular treatment has high success rate with low stroke/death rate. Carotid stenting (CAS) is an evolving alternative to surgery in the treatment of patients with carotid stenosis. Stent selection is influenced by several factors, including the carotid anatomy and lesion characteristics. We examined the wall adaptability of a new closed-cell carotid stent (NexStent), which was designed for carotid bifurcation treatment. Data obtained from angiographic and computed tomographic images indicate that the stent provides adequate expansion and adaptation to the carotid bifurcation.

There are two types of restenosis after carotid artery interventions: the early restenosis develops mainly within the first 24 months after the revascularization procedure and its pathological background is myointimal hyperplasia; on the other hand late restenosis is rather due to progression of primary atherosclerosis and occurs more than 2 years after carotid endarterectomy (CEA). We compared the early restenosis rate in a consecutive series of CAS versus CEA patients at a single cardiovascular institution. The data suggest that the incidence of restenosis after stenting was less common than after surgery.

Our results may help vascular surgeons and interventional radiologists to consider risk versus benefit when deciding treatment options for supraaortic arterial stenosis.

Percutaneous and open retrograde endovascular stenting of symptomatic high-grade innominate artery stenosis: technique and follow-up

BACKGROUND AND PURPOSE

Angioplasty and stenting of the IA have been reported with high technical and clinical success rates, low complication rates and good mid-term patency rates. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure of the CCA are used. The purpose of this study was to determine safety, efficacy and mid-term clinical and radiological outcome of the stent-assisted treatment of atherosclerotic stenotic disease of the IA with special focus on the different technical approaches.

MATERIALS AND METHODS

Between 1996 and 2008, 18 patients (12 men, 6 women) with symptomatic high-grade stenosis (>80%) of the IA were treated with endovascular stent placement. Their mean age was 60.4 years (range, 48-78 years). Mean angiographic and clinical follow-up was 2.7 years (range, 0.3-9.1 years). Clinical follow-up was performed by using the mRS at hospital discharge, routine follow-up controls, and a questionnaire. In 11 patients, a percutaneous approach was used. In 7 patients, the lesions were accessed retrogradely through a cervical cut-down with common carotid arteriotomy. In 2 patients, a simultaneous ipsilateral carotid endarterectomy was performed.

RESULTS

In all patients, primary stent placement was performed. There were 2 procedure-related transient complications (11.1%) due to cerebral embolism without permanent morbidity or mortality. During the follow-up, all patients showed improvement of the preprocedural symptoms. At the latest clinical follow-up (mean, 2.7 years), all patients showed an excellent or good outcome (mRS, 0 or 1). In 2 patients (11.1%), a secondary stent placement was needed due to a significant symptomatic in-stent stenosis.

CONCLUSIONS

Percutaneous and open retrograde stenting of high-grade stenosis of the IA is a viable less invasive alternatives to open bypass surgery with good midterm clinical results and patency rates.

Retrograde Supra-Aortic Stent Placement Combined With Open Carotid or Subclavian Artery Revascularization

Purpose: To review the outcomes of retrograde supra-aortic vessel stent (RSAS) placement combined with open carotid or subclavian artery revascularization. Methods: Retrospective review of all consecutive patients between 1995 and 2010, excluding transfemoral procedures or isolated retrograde stent placement. Results: There were 11 patients (9 females, mean age 65 years). Open revascularization included carotid endarterectomy in 6 patients, carotid-subclavian bypass in 3, and carotid-carotid bypass in 2 patients. There were no operative deaths or neurological events. All symptomatic patients improved. Over a mean follow-up of 24 months, One patient developed common carotid artery (CCA) in-stent dissection and symptomatic restenosis treated with subclavian-carotid bypass. Another 3 patients had asymptomatic restenosis of the carotid bifurcation but required no intervention. Conclusions: Retrograde stenting of the common carotid or innominate artery is a safe and effective method to provide inflow in selected patients with severe supra-aortic vessel disease who require concomitant open carotid or subclavian artery reconstructions.

Outcomes of angioplasty and stenting at the common carotid origin

BACKGROUND

Conventional treatment of stenosis at the common carotid artery origin has involved extra-anatomic bypass using an open cervical approach or median sternotomy. The goal of this study is to determine the procedural feasibility and safety of angioplasty and stenting at the common carotid origin as a less invasive alternative.

METHODS

Between March 1996 and November 2005, a total of 248 carotid angioplasty and/or stenting procedures were performed at our institution. Of these, 8 procedures were performed in 7 patients for treatment of a stenosis or dissection located at the common carotid origin. There were 4 males and 3 females with a mean age of 58 (range, 22-77). Five patients presented with neurologic symptoms. The patients' medical records were retrospectively reviewed for imaging reports (cerebral angiography, computed tomography, or ultrasound) and available clinical follow-up. Brief telephone interviews with patients, immediate family, or care personnel were also used. Procedural and midterm complication rates were calculated.

RESULTS

Of 8 procedures, 7 (87.5%) resulted in no residual stenosis. The procedural stroke rate was 0 (0%) of 8 procedures. The procedural TIA rate was 2 (25%) of 8 procedures. The mean follow-up was 31.7 months (range, 11.3-75.9 months). In 2 cases, follow-up was clinical only. In the remaining cases, there were clinical and imaging follow-up in the form of cerebral angiography (n = 3), CT angiography (n = 2), and ultrasound (n = 1). There was one recurrent TIA at 30 days and again at 3.1 months (1/8, 12.5%). There were no strokes (0/8, 0%) and there were no TIAs in patients who were initially asymptomatic on presentation. There was one death from an unrelated cause.

CONCLUSION

In this series, angioplasty and stenting were effective in relieving stenosis at the common carotid origin and have low rates of ischemic complications.

Evolving Strategies in Treatment of Isolated Symptomatic Innominate Artery Disease

Purpose: To examine the evolving roles of endovascular and open approaches in treatment of symptomatic innominate artery (IA) disease. Methods: Patients treated for symptomatic IA lesions with or without involvement of the right common carotid and/or right subclavian arteries between 1997 and 2006 were identified. Charts and diagnostic studies were retrospectively reviewed. Results: Of 18 patients treated, 8 required open reconstruction. Ten patients with high-grade focal stenosis were stented. Immediate technical and clinical success was 100% among all patients. Mean follow-up time was 25 and 27 months for endovascular and open interventions, respectively. The primary patency rates were 78% ± 14 and 80% ± 10 for endovascular and open groups, respectively. Assisted primary patency rate was 100% for both groups. There were no peri-operative mortalities or neurological events. We encountered two systemic (pulmonary) complications and one access-related complication among open and endovascular patients, respectively. Conclusion: Endovascular repair is evolving as a primary mode of therapy for focal IA lesions while open approach is reserved for more extensive disease. Patho-anatomical characteristics of a given IAlesion along with peri-operative risk assessment determine a proper surgical approach.

Endovascular management versus surgery for proximal subclavian artery lesions

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.

Stent-graft treatment of late stenosis of the left common carotid artery following thoracic graft placement

We report the case of a patient with subtotal occlusion of the origin of the left common carotid artery (CCA) following thoracic graft placement. Retrograde endovascular placement of a stent-graft by minimal cervical access was undertaken to repair the occlusive lesion of the left CCA and prevent future complications of endoluminal thoracic reconstruction. The retrograde endovascular repair of CCA lesions, as other authors have already suggested, may be the treatment of choice in "high-surgical-risk" patients. In these cases where the ostium of supra-aortic trunks is compromised following thoracic aorta stent-graft migration, endoluminal placement of a stent-graft in the CCA can guarantee both maintenance of carotid flow and thoracic stent-graft fixation.

Treatment of innominate arterial stenosis with self-expanding stent: long-term follow-up

We report our experience with the use of a self-expanding stent in the treatment of a severe innominate artery stenosis resulting in right upper limb ischemia. A 45-year-old woman was admitted for right upper limb ischemia, asymmetry of the carotid pulse and the lack of pulse in the right upper extremity. The patient had a history of chain smoking, hypertension, hypercholesterolemia, and acute myocardial infarction one year ago. She was diagnosed of the innominate artery stenosis by angiography one year ago at another hospital. At the time of admission her blood pressure was normal in the left arm and absent in the right upper limb. Arteriography showed a severe stenosis subocclusion of the innominate artery with an inverse flow of the ipsilateral vertebral artery. As the patient was not considered to be a surgical candidate due to instable angina, stent placement was indicated. After placement through an axillary approach an angiogram showed a patent right subclavian artery without residual stenosis. Angiographic follow-up showed a patent innominate arterial lumen two years after the procedure. The patient continued to be asymptomatic during six years follow-up. Blood pressure remained normal in both upper extremities, without any ischemic signs. Our experience indicates that placement of an endovascular stent is an effective therapeutic option in selected patients with symptomatic stenosis in the innominate artery when a surgical treatment is contraindicated.

Objective evaluation of upper limb claudication: use of isokinetic dynamometry

OBJECTIVE

The objective of this work is to present an objective, practical, and reproducible method for evaluating the functional limitation caused by occlusive arterial disease in upper limbs: a stress test using an isokinetic dynamometer.

METHODS

Twenty-three patients with unilateral subclavian artery occlusive disease were included in the study, forming group 1. Seven patients of similar age, with atherosclerotic or Takayasu's disease in the aorto-iliac segment, without subclavian artery occlusive disease, were included as a control group (group 2). For all tests, we utilized the CYBEX 6000 isokinetic dynamometer. The elbow was tested using a series of 30 repetitions of extension and flexion of the arm, performed up to a maximum of 270 repetitions (9 series) or until the limit of the tested limb was reached.

RESULTS

We initially compared all the limbs without arterial disease of both groups to analyze whether they presented similar functional performance. No significant difference was found for any of the parameters studied. Considering that upper limbs without arterial disease have a similar response to exercise in these analyzed parameters, we compared the upper limbs in group 1 (with and without subclavian artery occlusive disease). For all parameters, the limbs with subclavian artery occlusive disease presented significantly lower values than the control limbs (P < 0.05), which can be objectively attributed to the ischemia (there were different responses in different individuals, which allows the quantification of the limitation caused by subclavian artery occlusive disease).

CONCLUSION

In this study, we present a new stress test for impairment in patients with subclavian artery occlusive disease that might facilitate the classification of patients according to their functional impairment, and thus result in a better choice of therapeutic approach for each case as well as reporting of objective parameters that allow comparisons of the results of different treatments, including for long-term follow-up.

Percutaneous Angioplasty and Stenting of left Subclavian Artery Lesions for the Treatment of Patients with Concomitant Vertebral and Coronary Subclavian Steal Syndrome

OBJECTIVE

To evaluate the efficacy of subclavian stenosis percutaneous transfemoral angioplasty (PTA)-treatment in patients with intermittent or complete subclavian steal syndrome (SSS), and coronary-subclavian steal syndrome (C-SSS) after left internal mammary artery-interventricular anterior artery (LIMA-IVA) by pass graft.

METHODS

We studied 42 patients with coronary subclavian steal syndrome subdivided in two groups; the first group consisted of 15 patients who presented an intermittent vertebral-subclavian steal, while the second group consisted of 27 patients with a complete vertebral-subclavian steal. All patients were treated with angioplasty and stent application and were followed up for a period of 5 years by echocolordoppler examination to evaluate any subclavian restenosis.

RESULTS

Subclavian restenosis was significantly increased in patients with a complete subclavian steal syndrome. The restenosis rate was 6.67% in the first group and 40.75% in the second group, These patients had 9.1 fold-increase risk (CI confidence interval 0.95-86.48) in restenosis.

CONCLUSION

Patients with a complete subclavian and coronary steal syndrome present a higher risk of subclavian restenosis.

Perinatal management of right aortic arch with aberrant left subclavian artery associated with critical stenosis of the subclavian artery in a newborn

A right-sided aortic arch with an aberrant left subclavian artery is a congenital vascular anomaly that is easily detectable in utero at the level of the three vessels and trachea view, but which is rarely symptomatic in the neonate. We present a newborn with prenatally diagnosed right-sided aortic arch and aberrant subclavian artery who showed a clinically relevant stenosis of the subclavian artery during the first week of life. An intravascular stent was implanted into the stenosis of the aberrant left subclavian artery by catheterization. This case report demonstrates that a right-sided aortic arch with an aberrant subclavian artery can be diagnosed prenatally, that in these patients a stenosis of the subclavian artery can occur in early infancy and requires awareness of the neonatologist or pediatrician, and that stent implantation represents a minimally invasive therapeutic approach.

Primary Stenting of Subclavian and Innominate Artery Occlusive Disease: A Single Center?s Experience

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.

Subclavian artery stenting: factors influencing long-term outcome

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.

Endovascular Recanalization of Subclavian Artery Occlusions

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.

Ring-stripping retrograde common carotid endarterectomy: case report

CONTEXT

Total occlusion of the common carotid is rare and the indications and techniques for surgical treatment are still a matter of controversy.

OBJECTIVE

To demonstrate the feasibility of retrograde common carotid endarterectomy.

DESIGN

Retrospective case report study.

SETTING

Tertiary care private hospital.

PARTICIPANTS

Three patients underwent ring-stripping retrograde common carotid endarterectomy. Their ages were 81, 68 and 65 years. All were hypertensive with generalized atherosclerosis, two had diabetes mellitus, and one had undergone coronary artery bypass some years earlier and had non-dialytic chronic renal insufficiency. Symptoms of brain ischemia were present in two patients. All patients had total occlusion of the common carotid, extending from the origin to the bifurcation and localized in the right common carotid in two cases. In two cases the internal carotid artery was also occluded.

MAIN MEASUREMENTS

Postoperative early mortality and stroke rate, and the medium and long-term endarterectomy patency.

RESULTS

There were no deaths. One patient had a transient ischemic attack. All endarterectomies were patent after eight months, four years and seven years of follow-up.

CONCLUSION

There is low mortality, and the procedure can be done through only one cervical incision. Tandem lesions of the carotid arteries can be treated together. It is suitable for long total occlusions of the common carotid, and long-term patency.

Iatrogenic Subclavian Steal Syndrome

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