Subclavian artery stenting: Immediate and mid term clinical follow-up results

Endovascular Therapy of Symptomatic Innominate-Subclavian Arterial Occlusive Lesions

The purpose of this study was to determine the safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions by review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the innominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical examination (pulses and blood pressures) at 1, 3, 6, and then every 12 months plus an annual duplex ultrasound examination. Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48 to 89 years. Symptoms included vertebrobasilar/steal (15), claudication (6), ischemia (4), and coronary artery bypass grafting/left internal mammary artery (2). There were 7 occlusions and 20 high-grade stenoses. Access was attempted via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (10). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 occluded lesions could not be crossed owing to complete occlusion. The remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic blood pressure between upper limbs decreased from 36 mm Hg (preprocedure) to 10 mm Hg (postprocedure). There were no procedure-related complications. Mean follow-up was 18 months (range 1–62 months). One patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the percutaneous transluminal angioplasty/stent. Of the 4 successfully treated occlusions, 2 were followed up to 3 years with continued patency. Three patients developed recurrent stenoses documented by duplex examination. However, these patients remained asymptomatic and were not treated. Endovascular management of high-grade lesions of the subclavian or innominate arteries is safe and efficacious and may be considered as a first line of therapy. Continued follow-up is needed to assess long-term patency.

Stenting for chronic total occlusion of the proximal subclavian artery

SUMMARY

We report the results of 26 patients who underwent stent deployment for chronic total occlusion of proximal subclavian artery. From January 1998 to October 2005, 26 patients (18 male; mean age, 62.7 years, range 22 to 83 years), 28 lesions, underwent 29 procedures of stenting for chronic total occlusion of the proximal subclavian artery.Twenty-three patients had symptoms of claudication in their arm, no patients had subclavian steal syndrome.A brachial approach was used in 21 procedures, a femoral approach was used in five procedures, and combined femoral-brachial approach was required in three procedures. Primary stent deployment was success in 24 lesions (85.7%), and secondary procedure was success in one patient, totally 25 lesions (89.3%) were successfully treated by stenting. Procedure related complication occurred in four cases, including stent migration without symptoms in two procedures, hemianopsia on next day in a case, and TIA on unclear reason in one case. Permanent morbidity rate is 3.4% in procedure. Target lesion re-treatment required in three lesions, caused by subacute thrombosis, in-stent-restenosis, and dissection of the vessel by stent edge. The cases of subacute thrombosis and in-stent-restenosis were treated by re-PTA, and the case of dissection was treated by additional stenting. Secondary patency was 100%. We conclude that stenting for chronic total occlusion of subclavian arteries appears feasible and safe.

Bilateral occlusion associated to steal phenomenon of internal carotid and left subclavian arteries: treatment by angioplasty and stenting

OBJECTIVE

Treatment of subclavian artery occlusion is still a matter of controversy due to the short- and long-term complications and patency issues. We report an unusual case of combined occlusion of the proximal segment of the left subclavian artery and subclavian steal phenomenon associated with bilateral occlusion of the internal carotid arteries.

CASE DESCRIPTION

A 55-year-old male patient with previous history of myocardial infarction and hypertension presented with amblyopia and recurrent dizziness, mainly at work. Doppler fluxometry and digital subtraction angiography depicted proximal left subclavian artery occlusion and subclavian steal. Internal carotid arteries were occluded at the common carotid artery bifurcation. Percutaneous transluminal angioplasty and stenting (PTAS) were successfully performed by the left radial artery approach without complications. The patient had no recurrence of the symptoms, and the angiographic follow-up at 1 year showed good patency of the subclavian artery and normal flow through the left vertebral artery.

CONCLUSION

The planned approach for the case (PTAS) was performed without complications and evidence of restenosis in the angiography study at the completion of the first year of the treatment. The described strategy is safe and should be considered the first-choice procedure in the treatment of the subclavian occlusion.

Crush stenting of bifurcational left subclavian-vertebral artery stenosis

Left internal mammary artery (LIMA) has the best long-term patency in patients undergoing coronary artery bypass surgery. Stenosis of the proximal left subclavian artery (SA) may reduce flow to the LIMA, causing myocardial ischemia. We report a novel technique (crush stenting) for the treatment of a complex bifurcational left SA-vertebral artery (VA) stenosis in the presence of a patent LIMA bypass conduit. This technique limited plaque shifting, restored normal flow to all vessels, including the LIMA, and avoided devastating consequences of VA occlusion.