Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting

Purpose: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. Materials and Methods: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. Results: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2–month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. Conclusion: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Determinants of immediate and long-term results of subclavian and innominate artery angioplasty

BACKGROUND

Percutaneous angioplasty (PTA) is widely used in the treatment of subclavian/innominate artery obstruction, but factors of long-term PTA outcome are poorly understood. Our aim was to evaluate the efficiency of PTA on symptom resolution and identify determinants of long-term outcome.

METHODS AND RESULTS

Seventy-six lesions were treated in 75 patients (58.7% men) aged 60 +/- 8.5 years. PTA was successful in 70 (93.3%) patients, including 58/58 (100%) stenotic lesions and 13/18 (72.2%) occlusions. The mean stenosis grade (QCA) was reduced from 78.9% +/- 16.6% to 13.5% +/- 10.7% (P < 0.01). A great majority of lesions (87.1%) were stented. In 5 (7.1%) high-risk lesions a proximal or distal neuroprotection system was used. There were no strokes or embolic events. Minor complications occurred in 7 (9.3%) cases. Fifty-seven (89%) of 64 symptomatic patients had complete symptom resolution. The mean follow-up was 24.4 +/- 15.5 months (up to 66 months). Ten restenoses (15.6%), including 9 (13.8%) in-stent restenoses and 1 (16.7%) restenosis after balloon angioplasty, were diagnosed in 64 patients and followed up for at least 6 months. Nine symptomatic restenoses were successfully treated with repeated angioplasty. Cox multivariable analysis revealed the following independent predictors of restenosis: implantation of more than one stent (P = 0.005), low stent diameter (P = 0.088), and postprocedural systolic blood pressure difference between upper extremities (P = 0.044).

CONCLUSIONS

PTA is a safe and effective method for the treatment of the subclavian/innominate artery obstruction and leads to symptom resolution in majority of patients. Restenosis is not frequent and it can be effectively treated with repeat angioplasty. Low stent diameter, implantation of two stents, and upper limb systolic blood pressure difference are independent predictors of restenosis.

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.

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.

Axilloaxillary bypass for the treatment of subclavian artery stenosis complicated by bilateral common carotid artery occlusion: technical case report

OBJECTIVE AND IMPORTANCE

We successfully treated a patient with stenosis of the left subclavian artery, complicated by bilateral common carotid artery occlusion, via axilloaxillary bypass surgery.

CLINICAL PRESENTATION

A 67-year-old patient with a history of hypertension and cerebral infarction underwent neck irradiation for treatment of a vocal cord tumor. Three months later, he began to experience transient tetraparesis several times per day. The blood pressure measurements for his right and left arms were different. Supratentorial blood flow was markedly low. The common carotid arteries were bilaterally occluded, and the right vertebral artery was hypoplastic. Therefore, only the left vertebral artery contributed to the patient's cerebral circulation; his left subclavian artery was severely stenotic.

INTERVENTION

The patient underwent axilloaxillary bypass surgery because the procedure avoids thoracotomy or sternotomy, manipulation of the carotid artery, and interruption of the vertebral artery blood flow. The patient has been free of symptoms for more than 5 years.

CONCLUSION

Neurosurgeons should be aware that extra-anatomic bypass surgery is an effective treatment option for selected patients with cerebral ischemia.

Primary stent deployment in occlusive subclavian artery disease

Primary (without antecedent balloon dilation) Palmaz stent implantation was successfully performed in 27 consecutive patients entering with 31 obstructed subclavian arteries. Stents (n = 50) were successfully deployed, using the brachial (n = 7), femoral (n = 16), or combined (n = 8) approach, to revascularize 31 subclavian vessels [8 occluded (26%); 23 stenotic (74%)], using a 6 or 7.5 French delivery system. The indications for intervention were arm claudication in 8 patients (30%), subclavian steal syndrome in 11 patients (41%), angina pectoris secondary to impaired blood flow to the left internal mammary artery coronary bypass in 6 patients (22%), and recanalization of a left subclavian occlusion to permit central arterial access and performance of a second interventional procedure 2 patients (7%). The percent diameter stenosis improved from 85 +/- 12% to 6 +/- 7% (P < 0.001); and, the peak and mean translesion gradients decreased, respectively, from 56 +/- 35 mm Hg to 3 +/- 4 mm Hg (P < 0.01), and 29 +/- 18 mm Hg to 2 +/- 2 mm Hg (P < 0.01). Procedural complications encountered were one stent dislodgement with migration into and uneventful deployment within the right external iliac artery, and two brachial artery repairs. No acute vessel closures, deaths, myocardial infarctions, cerebrovascular accidents, transient ischemic attacks, or need for transfusions occurred. Therefore, primary subclavian artery stent deployment can be performed using low-profile sheath systems with excellent success (100%), resulting in immediate restoration of pulsatile flow, and few complications. The incidence of lesion recurrence remains for follow-up studies.

Angiographic evaluation of a carotid-subclavian bypass graft in a patient with subclavian artery stenosis and left internal mammary artery bypass graft

The incidence of coronary subclavian steal syndrome is estimated to be 0.4%. When revascularization is necessary, the preferred technique is the carotid-subclavian bypass graft. Failure of a carotid-subclavian graft is rare. We present a patient with subclavian stenosis who required reevaluation of both the carotid subclavian conduit and the left internal mammary bypass graft. A combined femoral and left brachial approach is recommended for evaluating the carotid-subclavian graft and left internal mammary artery graft in patients with bypassed subclavian artery stenosis and prior myocardial revascularization.