Risk stratification for subclavian artery angioplasty: is there an increased rate of restenosis after stent implantation?

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.

Outcomes of covered stents versus bare-metal stents for subclavian artery occlusive disease

Objective

To compare the clinical efficacy of covered stents and bare-metal stents in the endovascular treatment of subclavian artery occlusive disease.

Methods

Between January 2014 and December 2020, 161 patients (112 males) underwent stenting of left subclavian arteries; CSs were implanted in 55 patients (34.2%) and BMSs in 106 (65.8%). Thirty-day outcomes, mid-term patency, and follow-up results were analyzed with Kaplan-Meier curves. Relevant clinical, anatomical, and procedural factors were evaluated for their association with patency in the two groups using Cox proportional hazards regression.

Results

Mean follow-up was 45 ± 18 months. The primary patency was 93.8% (95% CI, 81.9%-98.0%) in the covered stent group and 73.7% (95% CI, 63.2%-81.6%; P = 0.010) in the bare-metal stent group. The primary patency in the total occlusion subcategory was significant in favor of CS (93.3%, 95% CI, 61.26%-99.0%) compared with BMS (42.3%, 95% CI, 22.9%-60.5%; P = 0.005). Cox proportional hazards regression indicated that the use of BMSs [hazard ratio (HR), 4.90; 95% CI, 1.47-16.31; P = 0.010] and total occlusive lesions (HR, 7.03; 95% CI, 3.02-16.34; P < 0.001) were negative predictors of patency, and the vessel diameter (HR, 3.17; 95% CI, 1.04-9.71; P = 0.043)) was a positive predictor of patency.

Conclusion

Compared with bare stents, covered stents have a higher midterm primary patency in the treatment of subclavian artery occlusive disease.

[Treatment of atherosclerotic lesion of the first segment of subclavian artery]

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Subtypes of the Completely Reversed Flow Waveform in Vertebral Artery Can Help to Differentiate Subclavian Artery Occlusion from Severe Stenosis

OBJECTIVES

To investigate the value of subtypes of completely reversed flow (CRF) waveform in vertebral artery (VA) on Doppler ultrasound in differentiation occlusion from severe stenosis of the ipsilateral proximal subclavian artery (SA).

METHODS

A total of 357 patients with CRF in the VA on Doppler US were reviewed retrospectively. Among them, 49 patients (mean age, 68.2 ± 7.8 years) confirmed by digital subtraction angiography (DSA) were included. According to the status of diastolic flow, the CRF was divided into continuous CRF (CCRF, n = 27) and intermittent CRF (ICRF, n = 22). The correlation of subtypes of CRF waveform and VA parameters with the severity of SA stenosis was evaluated. The severity of SA stenosis was determined by DSA.

RESULTS

Of those 49 patients, SA occlusion was observed in 33 patients (67%, occlusion group) and severe stenosis in 16 patients (33%, stenosis group). The subtypes of CRF waveforms showed a significant between-group difference (p = 0.005). CCRF exhibited an accuracy of 85.2% (23/27) in diagnosing SA occlusion. The diameter of the target VA with ICRF showed a significant between-group difference (p = 0.041). The target VA diameter ≥ 3.8 mm in ICRF achieved an accuracy of 81.8% (18/22), and its combination with CCRF achieved an accuracy of 83.7% (41/49) in the differentiation of SA occlusion from severe stenosis.

CONCLUSIONS

Subtypes of CRF in VA can help to differentiate SA occlusion from severe stenosis. CCRF has higher accuracy in diagnosing SA occlusion. The CCRF waveform plus VA diameter in ICRF is more accurate for differentiating SA occlusion from severe stenosis.

Angioplasty versus stenting for subclavian artery stenosis

BACKGROUND

The subclavian arteries are two major arteries of the upper chest, below the collar bone, which come from the arch of the aorta. Endovascular treatment for stenosis of the subclavian arteries includes angioplasty alone, and with stenting. There is insufficient evidence to guide the use of stents following angioplasty for subclavian artery stenosis. This is the second update of a review first published in 2011.

OBJECTIVES

The aim of this review was to determine whether stenting was more effective than angioplasty alone for stenosis of the subclavian artery.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and LILACS databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 2 February 2021.

SELECTION CRITERIA

We searched for randomised controlled trials of endovascular treatment of subclavian artery lesions that compared angioplasty alone and stent implantation.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, we asked a third review author to assess the study for inclusion. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions, and assess the certainty of the evidence using a GRADE approach.

MAIN RESULTS

To date, we have not identified any completed or ongoing randomised controlled trials that compare percutaneous transluminal angioplasty and stenting for subclavian artery stenosis.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery

INTRODUCTION

Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery.

METHODS

Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included.

RESULTS

Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery. 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted in 15 patients. Central luminal passage was not achieved in one patient because of the subintimal position of the guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. The patency rate at two years was 93.3%.

CONCLUSION

Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results.

Endovascular therapy of axillary artery disease with drug-coated balloon angioplasty

The occurrence of upper-extremity arterial disease is less common than that of the lower extremities. Nevertheless, exercise-induced symptoms, when present, can significantly affect functional capacity and limit quality of life. We report a case of exertional right upper-extremity pain and severe right axillary artery disease that was revascularized using an off-label drug-coated balloon technology with resolution of symptoms.

Subclavian Artery Disease: Diagnosis and Therapy

The diagnosis of brachiocephalic disease is often overlooked. Symptoms include arm claudication and vertebrobasilar insufficiency. In patients who have had the use of the internal mammary artery for coronary bypass surgery, the development of symptoms of myocardial ischemia should alert the clinician to the possibility of subclavian artery stenosis. Also, in patients who have had axillofemoral bypass, lower-extremity claudication may occur. Recognition involves physical examination and accurate noninvasive testing. Endovascular therapy has proven to be effective in alleviating symptoms in properly selected patients.

Endovascular Treatment of the Subclavian Artery Steno-Occlusive Disease

OBJECTIVE

The aim of our study was to compare immediate and long-term results of endovascular interventions for the treatment of steno-occlusive disease of subclavian arteries (SAs) depending on the length of lesion.

MATERIALS AND METHODS

Between 2010 and 2013, we performed 245 endovascular procedures to treat patients with atherosclerotic steno-occlusive disease of SAs. All patients were examined and subdivided according to the received results into 2 groups: 125 patients with stenosis of SA were included in the first group and 120 patients with occlusion of SA were included in the second group. The patients were then followed up at 6, 12, 24, 36, and 48 months after endovascular interventions. Follow-up visits contained symptomatic evaluation, clinical assessment with physical examination, complete neurological evaluation, and serial color Doppler ultrasonography.

RESULT

Transitory ischemic attacks in the vertebrobasilar system were intraoperatively developed by 1 patient from the first group (.8%) and 3 patients from the second group (2.5%). Reinterventions in the long-term period were carried out in 9 (7.2%) cases in the first group and 12 (10%) cases in the second group (P = .43). The cumulative primary stent patency at 4 years was 89.8% in the first group and 87% in the second group (P = .4).

CONCLUSIONS

In the case of SA occlusion on the first stage, it is expedient to carry out endovascular recanalization followed by stenting. Our study revealed an increased risk of stent thrombosis or in-stent restenosis in patients with stents >40 mm.

Results of Transradial Subclavian Artery Percutaneous Interventions After Bilateral or Single Access

Percutaneous treatment of subclavian artery stenosis or occlusion has become more popular compared with surgical correction. We compared the early and late results of subclavian artery stenting with bilateral or single transradial access. From 2010 to 2015, we recruited 54 consecutive patients. In 35 cases, we used bilateral access, and in 19 cases, ipsilateral single access was used. Left subclavian artery was the culprit vessel in 72% of cases. There were more chronic total occlusions in the bilateral group (77% vs 21%, p = 0.0001). Transradial-only approach was used in all cases, except in 2 cases in the bilateral group where crossover to femoral access was required. Stents were implanted in 94% in bilateral group and 84% in single group (p = 0.47). Procedure duration (40 [35 to 60] vs 20 [15 to 30] minutes), contrast volume (200 [200 to 350] vs 150 [100 to 200] ml and fluoroscopy time (20 [12 to 30] vs 8 [4 to 11] minutes) were higher in bilateral group (all p values <0.0001). Procedural success was 96%. Overall, we observed three <5-cm hematomas and 3 asymptomatic radial artery occlusions at hospital discharge. After successful procedure, blood pressure equalized in 94% in bilateral group and 100% in single group (p = 0.54). Major cardiovascular and cerebrovascular event-free survival up to 5 years was 97% in bilateral group compared with 84% in single group (p = 0.12). Subclavian artery patency at late follow-up was 91% in bilateral group and 95% in single group (p = 1.00). Using single or bilateral transradial approach, subclavian artery lesions or occlusions can be effectively and safely treated without the risks of femoral or brachial access.

Ten-year experience in subclavian revascularisation. A parallel comparative observational study

Introduction

Subclavian stenosis has a prevalence of approximately 2% in the community, and 7% within a clinical population. It is closely linked with hypertension and smoking. There is a relative paucity of published data to inform clinicians on the optimal mode of treatment for subclavian artery stenosis.

Objectives

To compare clinical outcomes of subclavian bypass surgery with that of subclavian endovascular re-vascularisation. Endpoints were survival time, re-intervention-free survival, and symptom-free survival.

Method

In all, 21 subclavian interventions were performed from 2000 to 2010. We compared angioplasty vs angioplasty with stenting vs bypass.

Results

Technical success was 100% in all groups. Symptom-free survival, at 70 months, was 60% in the angioplasty group, 100% in the angioplasty and stenting group and 75% in the bypass group. Re-intervention rate was 40% in the angioplasty group, 0% in the angioplasty and stenting group and 25% in the bypass group. Median time for re-intervention was 9.5 months in angioplasty patients and 36 months in bypass patients ( p = 0.102). Target lesion revascularisation was 20.0% for angioplasty procedures, 16.67% for angioplasty and stenting and 25% for bypass procedures.

Conclusion

Angioplasty with stenting provides improved symptom-free survival and freedom from re-intervention in patients with symptomatic subclavian artery stenosis.

Left Subclavian Artery Occlusion: Femoro-Axillary Artery Retrograde Bypass

The treatment tactics for subclavian artery occlusion include the more commonly used endovascular therapy rather than surgical intervention. We present a case of a 61-year-old woman with dialysis-dependent chronic renal failure who experienced left finger necrosis in the left upper extremity. To salvage the limb, we performed femoro-axillary (fem-ax) artery bypass using an autologous saphenous vein graft. However, 10 months later, she experienced coldness in the left forearm. Angiography revealed chronic total occlusion of the venous bypass. Despite emergent thrombectomy, redo fem-ax artery bypass operation was performed using a prosthetic graft. Upper limb salvage can be achieved by fem-ax artery retrograde bypass.

Waveform patterns and peak reversed velocity in vertebral arteries predict severe subclavian artery stenosis and occlusion

This study investigated the value of analyzing spectral Doppler waveform patterns and measuring the peak reversed velocity (PRV) of the vertebral artery (VA) in predicting proximal severe subclavian artery (SA) stenosis and occlusion. Fifty-one patients with proximal SA stenosis were studied retrospectively. Based on the depth of the mid-systolic notch, the Doppler waveforms of the ipsilateral VA were divided into five subtypes (type I, n = 8; type II, n = 8; type III, n = 6; type IV, n = 13; and type V, n = 16). PRV was also measured. PRV receiver operating characteristic curves were constructed to obtain the best cutoff value for predicting severe SA stenosis or complete SA occlusion. The results indicated that both VA Doppler waveform and PRV were associated with the degree of SA stenosis (p < 0.05). PRV and the Doppler waveform in the VA had similar accuracy in predicting SA occlusion (84.3%, 43/51). PRV was more accurate than VA waveforms in predicting severe SA stenosis (98%, 50/51 vs. 94.1%, 48/51). However, no significant differences between the two methods in predicting severe SA stenosis were observed (p = 0.84). Thus, with severe obstruction of the SA, typical Doppler waveform patterns of the VA could be observed. PRV is a helpful criterion in predicting severe stenosis and occlusion of the SA.

Angioplasty versus stenting for subclavian artery stenosis

BACKGROUND

There is insufficient evidence to guide stent usage following angioplasty in subclavian artery stenosis. This is an update of a review first published in 2011.

OBJECTIVES

The aim of this review was to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 1). There was no restriction on language.

SELECTION CRITERIA

Randomised controlled trials of endovascular treatment of subclavian artery lesions comparing angioplasty alone and stent implantation.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated studies to assess eligibility. Discrepancies were resolved by discussion. If there was no agreement, the third author was asked to assess the study for inclusion.

MAIN RESULTS

To date we have not identified any completed or ongoing randomised controlled trials comparing percutaneous transluminal angioplasty and stenting for subclavian artery stenosis.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine whether stenting is more effective than angioplasty alone for stenosis of the subclavian artery.

Japanese Registry of Neuroendovascular Therapy: extracranial steno-occlusive diseases except for internal carotid artery stenosis

Although utilization of endovascular treatment of extracranial steno-occlusive lesions except for internal carotid artery stenosis continues to increase, there is no consensus regarding the natural course and standard treatment of these lesions. The aim of this study was to characterize the utility of endovascular treatment for extracranial steno-occlusive lesions except for internal carotid artery stenosis. A total of 1249 procedures for extracranial steno-occlusive lesions were identified from the Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET2. Excluding the cases of carotid lesions (290 cases), endovascular procedures were performed for 471 (37.7%) subclavian artery stenoses, 404 (32.3%) extracranial vertebral artery stenoses, and 38 (3.0%) innominate artery stenoses with a technical success rate of 97.2%. A stent was placed for 783 lesions and percutaneous transluminal angioplasty was performed for 183 lesions. Forty complications were reported in this cohort. Among these, ischemic complications were the most frequent (12 cases). Comparison between JR-NET1 and JR-NET2 demonstrated a marked increase in the number of procedures, a change in the utilization of antiplatelet therapy, and an increased rate of favorable outcome. We conclude that the endovascular treatment for extracranial steno-occlusive lesions is relatively safe. Continuous efforts should be made to reduce the complication rate, and further trials are needed to validate the beneficial effect of this procedure.

Endovascular stenting for atherosclerotic subclavian artery stenosis in patients with other craniocervical artery stenosis

Atherosclerotic subclavian artery stenosis (SAS) accompanied with other craniocervical artery stenosis (OCAS) is not uncommon in practice. We sought to investigate the safety and efficacy of endovascular stenting for SAS in patients with OCAS. Between January 2004 and February 2012, 71 consecutive atherosclerotic SAS patients who underwent primary stenting in our medical center were included. The enrolled patients were divided into combined-SAS group (n = 51) and solitary-SAS group (n = 20) depending on the presence or absence of OCAS. Data of demographics, procedure, and the followed-up were retrieved and analyzed. The technical success rate was 95.8%; the clinical success rate was 90.1%. There was no catheter-related major stroke or death. The immediate outcomes had no statistical difference between groups. During a mean of 27 ± 20 months (range 2-88 months) followed-up, 7 (10.3%) restenosis and 12 (17.6%) clinical events were identified. The primary patency rate was 95.3, 84.9 and 84.9% at 12, 24 months, and final followed-up respectively, which had no statistical difference between groups (odds ratio (OR), 2.60; 95% confidence interval (CI), 0.54-12.53; P = 0.232). The overall clinical event-free survival rate was 93.5, 86.2 and 54.6%, respectively, where the result of combined-SAS group was inferior to that of the solitary-SAS group (OR, 3.34; 95% CI, 1.02-11.00; P = 0.047). Endovascular stenting was safe and feasible for atherosclerotic SAS in patients with OCAS, although the combined OCAS may have a significant influence on the long-term outcome. Further studies are warrant to investigate the effects of revascularization for multiple craniocervical artery stenoses on the cerebral hemodynamics and long-term outcomes.

Síndrome do roubo coronário-subclávio: relato de caso e revisão da literatura

O fenômeno do roubo coronário-subclávio é definido como o fluxo sanguíneo invertido de uma artéria coronária, por meio de enxerto de artéria mamária interna em direção à subclávia médio-distal, e ocorre devido à estenose significativa ou oclusão total da porção proximal desta última. É uma causa rara, mas significante, de isquemia cardíaca após cirurgia de revascularização miocárdica e pode originar uma síndrome de mesmo nome e com manifestações típicas. Relatou-se o caso de um paciente com esta enfermidade, que foi submetido à angioplastia percutânea com implante de stent. Também revisou-se a literatura a respeito.

The Use of Protection Device in Landmark-wire Technique of Symptomatic Subclavian Artery Occlusion with Combined Approach via Trans-femoral vs. Trans-brachial Arteries: Technical note

PURPOSE

Since we reported about a landmark technique to reopen an occluded subclavian artery, we have faced difficulty in using protection devices in the vertebral artery to protect against thromboembolism from the reversed steal phenomenon after angioplasty and stenting. Therefore, we are presenting an optimal solution in using a protection device while recanalizing the occluded subclavian artery.

MATERIALS AND METHODS

Among 21 cases of stenting for subclavian artery steno-occlusion, we applied the landmark technique at the opposite end of an occluded segment in 4 patients and used a protection device in two patients. Because the embolic protection device was placed in the vertebral artery via the brachial artery, optimal angioplasty and stenting via the brachial route were limited. Therefore, angioplasty via the trans-brachial approach was needed to be followed by stenting through a trans-femoral approach. We estimated the safe and optimal steps for placement and retrieval of the protection devices in addition to stenting.

RESULTS

The procedure was safely performed when a stent was introduced via the femoral artery and a protection device was used via the brachial artery. However, in cases when a guidewire wasn't passed via the transfemoral route, simultaneous use of two systems via the brachial route could cause friction of devices or trapping of protection devices in a stent. When a protection device was trapped in a deployed stent, we retrieved the protection device with a 4F angiocatheter by selectively rotating the catheter tip. To avoid such procedural difficulty, we recommend using a transbrachial angioplasty followed by trans-femoral stenting while placing the protection device in the vertebral artery via the trans-brachial route.

CONCLUSION

If a guidewire is not passed through using a trans-femoral approach while performing the landmark technique, changing the stenting route from brachial to the femoral artery can be useful after securing the lumen in the occluded subclavian artery after angioplasty via the brachial artery.

Subclavian artery stenosis: a review for the vascular medicine practitioner

Peripheral artery disease assessment typically focuses on the evaluation of lower extremity symptoms and physical findings. Few practitioners consider the importance of upper extremity arterial disease; which, besides causing hand and arm symptoms, can be associated with significant neurologic and cardiac sequelae. A review of the existing literature through PubMed using the search term 'subclavian stenosis' was performed. The latest original articles, including clinical studies, case reports and limited reviews of this topic were adapted. A comprehensive article review focusing on the diagnostic and treatment approach for subclavian stenosis was prepared. In conclusion, vascular medicine practitioners including cardiologists and vascular surgeons caring for patients with arterial disease should routinely assess for subclavian stenosis. There are excellent screening tools and effective medical therapies which can be instituted if 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.

Landmark-wire technique of symptomatic subclavian artery occlusion

SUMMARY

The landmark at the opposite end of an occluded segment can be used for probing the occluded subclavian artery to be recanalized. Using this technique in three patients with symptomatic subclavian artery occlusion, we found the landmark-wire technique to be safe and effective for reopening completely occluded subclavian arteries. We also introduced a technique in which a protective device can be safely used throughout the stenting procedure.

A case report of coronary-subclavian steal syndrome treated with carotid to axillary artery bypass

Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. This rare complication of cardiac revascularisation leads to recurrence of myocardial ischaemia. When feasible, subclavian angioplasty and/or stent placement can provide acceptable result for these patients. Vascular reconstruction through carotid to subclavian artery bypass has been the standard procedure of choice. Other interventions in literature include axilloaxillary bypass and subclavian carotid transposition. This case report describes the use of carotid axillary artery bypass for the treatment of coronary-subclavian steal syndrome.

Closure of the subclavian artery puncture site with a percutaneous suture device after removal of an arterial pacemaker lead

We describe the closure of a subclavian artery puncture site with a percutaneous suture device after removal of a pacemaker lead 1 week after its inadvertent positioning in the left ventricle via the subclavian artery. The lead was retracted from the left ventricle into the aorta and linked to a guiding catheter introduced via femoral artery access. The lead and the guiding catheter were removed from the artery to the subclavian area. This manoeuvre allowed the placement of a percutaneous arterial suture device (Perclose) to close the puncture site.

The role of multi-slice spiral CT angiography in patient management after endovascular therapy

OBJECTIVES

To bring out the role of multi-slice spiral CT angiography (MS-CTA) in patient management after endovascular therapy of subclavian artery stenosis.

METHODS

Twenty-one consecutive patients with clinically suspected restenosis after endovascular treatment of subclavian artery stenosis or occlusion were included in the study. Eleven patients had been treated with percutaneous transluminal angioplasty (PTA) alone and 10 with PTA and stenting. The mean follow-up period after PTA or stenting was 57 (+/-27 SD) months. CTA was performed using a bolus-triggered high-resolution protocol with biphasic intravenous contrast medium injection. Axial images and curved planar reformations (CPRs) were rated by three readers with regard to patency of supra-aortic vessels. Imaging findings were correlated with a standardized clinical assessment.

RESULTS

All examinations were of diagnostic quality. Of 21 referred patients, 7 had significant reobstruction of the treated subclavian artery. Six of the 7 patients with significant restenosis on CTA were treated conservatively (antiplatelet agents), despite 2 of them being symptomatic on the standardized clinical assessment, which showed a sensitivity and specificity of 86% in predicting stenosis. One patient was treated with PTA and stent deployment because of strong subjective suffering.

CONCLUSION

MS-CTA is useful for exclusion or quantification of clinically suspected restenosis in carefully selected patients after endovascular therapy where ultrasound is inconclusive and/or contrast-enhanced magnetic resonance angiography is contraindicated.

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.

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.

Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: Long-term results

PURPOSE

Percutaneous transluminal angioplasty (PTA) is one of the treatment options for localized obstruction of the subclavian artery. To document long-term durability of this kind of PTA we report a 10-year single-center experience in 110 patients.

METHODS

From January 1993 to July 2003, 110 patients (72 women; mean age, 62 +/- 10 years) underwent PTA of symptomatic (>75%) stenosis (n = 90) or occlusion of the proximal subclavian artery (84 left-sided). Forty one patients (37%) had symptoms of vertebrobasilar insufficiency, 29 patients (26%) had disabling chronic arm ischemia, and 20 patients had both symptoms. Twenty patients with coronary artery disease underwent PTA in preparation for myocardial revascularization with the internal mammary artery. Duplex scans and arteriograms confirmed significant stenosis or occlusion. All PTA procedures were performed with the patient under local anesthesia, through the femoral artery (n = 89), brachial artery (n = 6), or combined route (n = 15). In 59 patients (58%) an additional stent was placed.

RESULTS

Angioplasty was initially technically and clinically successful in 102 patients (93%). Seven occlusions could not be recanalized, and 1 procedure had to be stopped because of ischemic stroke. Of the 102 patients in whom treatment was successful, 1 patient (1%) had a minor stroke in the contralateral hemisphere 2 hours post-PTA. Seven patients (7%) had minor problems, all without permanent sequelae. Follow-up with duplex scanning ranged from 3 months to 10 years (mean, 34 months). Primary clinical patency at 5 years was 89%, with a median recurrent obstruction-free period of 23 months. The local complication rate was 4.5%, and the combined stroke and death rate was 3.6%. Significant recurrent obstruction (>70%) developed in 8 patients with clinical symptoms. Four stenoses were successfully treated with repeat PTA (2 with additional stent placement); 4occlusions required surgery.

CONCLUSIONS

PTA of obstructive lesions of the proximal subclavian artery is not only an effective initial treatment, but is also successful over the long-term. Inasmuch as all clinical failures occured within 26 months after initial therapy, we recommend regular follow-up for at least 2 years post-PTA. All clinically significant recurrent stenoses can be treated with repeat endovascular procedures. We could not prove positive or negative influence of additional placement of stents; however, the number of recurrent stenoses might be too small in this retrospective study to draw firm conclusions. Adverse events of any kind are certainly no greater than with invasive surgical procedures. Therefore PTA must be seriously considered in patients with localized obstruction of the proximal subclavian artery.

Endovascular treatment of the subclavian artery: Stent implantation with or without predilatation

The endovascular treatment of subclavian artery (SA) lesions is less invasive than open surgical repair, with a low rate of complications. We report our experience in 89 subclavian obstructive lesions (n = 86) treated with stenting: 76 (85.3%) stenoses and 13 (14.6%) total occlusions. The left side was most frequently involved (83.1%), localized at the prevertebral segment in 91%. Technical success was obtained in 83 (93.3%) cases, 100% in stenotic lesions and 53.8% in total occlusions. There were nine global complications (10.1%): five (5.6%) at site of puncture, two distal embolization (2.2%), and two (2.3%) major events. The long-term follow-up was 3.51 +/- 1.98 years, during which time 13 (16.8%) restenoses and 2 (2.6%) reocclusions were noted. Subgroup analysis of patients with stenting after predilatation versus direct stenting technique showed in-hospital complications only in the first group, with a restenosis rate of 28.5% vs. 4.7%, respectively (P = 0.003). We consider stenting for SA obstructive lesions the first therapeutic option.

Extracranial revascularization therapy: Angioplasty and stenting

Beginning with simple balloon angioplasty, minimally invasive revascularization techniques have progressed to the use of metallic stents for improved immediate and long-term results. Stent-supported angioplasty now offers a therapeutic option for those individuals ineligible for surgical revascularization of stenotic atherosclerotic lesions and who have failed maximal medical therapy. However, the clinical equivalence, or possibly even superiority, of angioplasty of the extracranial carotid and vertebral arteries in atheromatous occlusive disease over surgical revascularization has yet to be determined in ongoing randomized controlled trials. Additionally, endovascular techniques offer treatment for a variety of nonatherosclerotic disease affecting the extracranial arteries, such as inflammatory, radiation-induced, and postsurgical strictures; acute intimal dissection; traumatic and spontaneous arteriovenous fistulas; and aneurysms or pseudoaneurysms. For certain disease entities at high risk for surgical complications, endovascular procedures have gained preference as the therapeutic modality of choice, yet lacking controlled trials providing evidence for noninferiority against surgical approach. Continued innovation and refinement of endovascular technology and techniques will further improve technical success, reduce procedure-related morbidity, and broaden the endovascular therapeutic spectrum for extracranial and intracranial cerebrovascular disease.

Percutaneous recanalization of chronic subclavian artery occlusion using optical coherence reflectometry-guided radiofrequency ablation guidewire

Subclavian artery lesion that is associated with low complication rate could be treated by percutaneous intervention effectively. However, the success of endovascular therapy for occlusive lesion may be limited by failure to cross with a guidewire. We describe the use of a system using optical coherence reflectometry for navigation and radiofrequency ablation to enable wire passage through subclavian artery occlusion that could not be crossed by conventional guidewires.

Approach to patients with "complex" hemodialysis access problems

The approach to patients with "complex" permanent hemodialysis (HD) access problems remains poorly defined. The purpose of this review is to outline our current algorithm for patients presenting for dialysis access and to address the management of specific problems that complicate this objective of establishing permanent access. The key components of the algorithm include noninvasive imaging in the diagnostic vascular laboratory to determine all the possible access configurations and invasive imaging with both venography and arteriography to confirm the optimal choice. The specific access-related problems addressed include inadequate ipsilateral vein, inadequate arterial inflow, central vein stenosis/occlusion, multiple previous access failures, and obesity. Despite the label of "complex" access problems, it is possible to construct native arteriovenous fistulas (AVFs) in almost all patients presenting for access using the standard principles of vascular surgery that are based on establishing adequate arterial inflow, adequate venous outflow, and selecting an appropriate conduit.

Restenting for subclavian in-stent restenosis with symptomatic recurrent coronary-subclavian steal

PURPOSE

To determine whether restenting for recurrent coronary-subclavian syndrome is technically feasible, provides durable results, and is a reasonable alternative to surgery.

CASE REPORT

A 58-year-old woman with a left internal mammary artery (LIMA) bypass to the left anterior descending artery underwent angioplasty and stent placement for left subclavian stenosis and coronary-subclavian steal. Twenty-three months later, she returned with progressive angina and left arm claudication; heart catheterization demonstrated restenosis of the subclavian artery at the stent site with recurrence of the coronary-subclavian steal. Successful redo angioplasty and stenting resulted in normal antegrade flow through the LIMA graft. The patient has remained asymptomatic for 3 years without evidence of recurrent in-stent stenosis on serial noninvasive studies.

CONCLUSIONS

Restenting is technically feasible and appears to be a durable response to subclavian in-stent restenosis in patients with coronary subclavian steal.

Outcome of conservative versus interventional treatment of subclavian artery stenosis

PURPOSE

To compare the outcome of conservative treatment versus percutaneous transluminal angioplasty (PTA) of subclavian artery stenosis in terms of long-term hemodynamic and symptomatic outcome in a retrospective, nonrandomized study.

METHODS

Within a 14-year period, 295 consecutive inpatients were treated for subclavian artery stenosis. Excluding 21 (7%) surgical cases, the remaining 274 patients were treated either conservatively (n = 165) or with PTA (n = 109). Medical history, physical findings, and sonographic and angiographic data were recorded from the medical records of the 223 (81%) patients who were followed until the year 2000; 166 patients were then reinvestigated with oscillography, Doppler measurements, and duplex sonography. Outcomes of conservative versus interventional therapy were analyzed based on the intention to treat principle.

RESULTS

After a median 42-month follow-up (interquartile range 18-85), patients treated with PTA had a 60% risk reduction for hemodynamic subclavian stenosis compared to conservative treatment (adjusted hazard ratio 0.4, 95% confidence interval 0.2-0.6, p<0.0001). However, the risk of having a symptomatic stenosis at the time of follow-up did not differ between the treatment groups (p=0.3).

CONCLUSIONS

Endovascular revascularization improves the long-term hemodynamic outcome in patients with subclavian stenosis, but many conservatively treated patients become asymptomatic during follow-up. Interventional treatment may be considered primarily for patients with severe symptoms of vertebrobasilar insufficiency, critical ischemia, or peripheral emboli.

Regulation of p21WAF1/CIP1 expression through mitogen-activated protein kinase signaling pathway

p21WAF1/CIP1 is a cyclin-dependent kinase inhibitor whose expression in mammalian tissues is highly induced in response to stress as well as during normal development and differentiation. Induction of p21WAF1/CIP1 in response to DNA damage occurs through a transcriptional mechanism that is dependent on the activation of the tumor suppressor protein p53. Recent evidence indicates that p21WAF1/CIP1 can also be induced independently of p53, but the signal transduction mechanisms involved in regulating p21WAF1/CIP1 expression in these situations have not been elucidated. In this study, we have addressed the role of the mitogen-activated protein kinase signaling pathway in the induction of p21WAF1/CIP1 in response to growth factor treatment. Using an experimental approach involving cotransfection of a p21WAF1/CIP1 promoter-luciferase construct with a variety of plasmids expressing dominant positive or dominant negative mutant proteins involved in this signaling pathway, we provide evidence to support a role for mitogen-activated protein kinase in the transcriptional activation of p21WAF1/CIP1 by growth factor stimulation.