Subclavian Stents and Stent-Grafts: Cause for Concern?

Traumatic Subclavian Artery Pseudoaneurysm: Periprocedural Salvage of Failed Stent-Graft Exclusion Using Coil Embolization

Purpose:

To report the exclusion of a subclavian pseudoaneurysm by a combination of covered stent implantation and coil embolization.

Case Report:

A 30-year-old man presented with a posttraumatic pseudoaneurysm of the left subclavian artery. A covered Jostent was inserted via a percutaneous femoral approach and deployed in the injured subclavian artery. Because of tapering of the artery proximally, apposition of the covered stent to the arterial wall was insufficient, leading to persistent filling of the pseudoaneurysm. Exclusion of the pseudoaneurysm was achieved by coil embolization through a gap between the stent-graft and the arterial wall.

Conclusions:

This report illustrates that successful endovascular treatment of a left subclavian pseudoaneurysm may require a combination of catheter-based techniques.

Endovascular Exclusion Of Subclavian Artery Pseudoaneurysm

Subclavian artery pseudoaneurysms are typically a rare occurrence commonly caused by iatrogenic injury and trauma. We describe an endovascular approach employing a brachiofemoral through-wire technique for the treatment of a left subclavian artery pseudoaneurysm in the presence of a hostile aortic arch and great vessel anatomy.

Early Stent Graft Perforation after Endovascular Repair for Pseudoaneurysm That Was Associated with Clavicle Nonunion

We report the case of a 62-year-old man who experienced a left axillary artery pseudoaneurysm that was secondary to nonunion of a 30-year-old left midshaft clavicle fracture. He initially underwent endovascular repair using a self-expanding nitinol stent graft, which was perforated at postoperative day 5. Therefore, we performed open repair with concomitant clavicle resection, and no complications were observed during an approximately 6-year follow-up. We recommend performing clavicle resection with vascular repair to prevent recurrence in similar cases.

Hemodialysis Reliable Outflow device impingement in the subclavian position: a case report

PURPOSE

The purpose of this study is to report a case of Hemodialysis Reliable Outflow (HeRO) device malfunction in the subclavian position secondary to costoclavicular impingement.

METHODS AND RESULTS

The electronic medical record was reviewed for the patient in question and pertinent imaging was collected and photographs were taken with the patient's consent. The patient presented with signs of outflow obstruction after a period of HeRO venous outflow component function. The outflow component was found to be crushed between the first rib and the clavicle at the costoclavicular junction.

CONCLUSIONS

This case suggests that costoclavicular impingement should be considered as a mode of outflow failure with the HeRO outflow component in the subclavian position. Other central venous access points should be considered first, and the central veins accessed through the lower extremities are possible alternatives if this failure mode was to arise. First rib resection would also be a viable strategy to relieve impingement at this site.

Endovascular repair of subclavian/axillary artery injury with a covered stent. A case report and review of literature

Experience with and acceptance of endovascular repair of arch vessel injuries continues to increase. This manuscript reports the case of a 65-year-oldman with a gunshot wound to the right supraclavicular area with a hematoma, pulsating mass and loss of neurological function of the right upper extremity. As he was hemodynamically stable, a computed tomography angiogram was performed and it demonstrated a 6 cm right subclavian/axillary artery pseudoaneurysm. The patient was taken to the angiogram/hybrid room and an arch angiogram was performed. A selective right subclavian angiogram was performed and a covered stent was deployed across the pseudoaneurysm and a completion angiogram showed complete exclusion with normal runoff to the upper extremity. In conclusion, penetrating subclavian/axillary artery trauma can be successfully managed with minimal morbidity via early utilization of endovascular covered stent therapy. A literature review suggests that the endovascular approach will soon be the standard of care for traumatic disruption of subclavian arteries.

Effort thrombosis presenting as pulmonary embolism in a professional baseball pitcher

Context:

Effort thrombosis, or Paget-Schroetter’s syndrome, is a rare subset of thoracic outlet syndrome in which deep venous thrombosis of the upper extremity occurs as the result of repetitive overhead motion. It is occasionally associated with pulmonary embolism. This case of effort thrombosis and pulmonary embolus was in a 25-year-old major league professional baseball pitcher, in which the only presenting complaints involved dizziness and shortness of breath without complaints involving the upper extremity—usually, a hallmark of most cases of this condition. The patient successfully returned to play for 5 subsequent seasons at the major league level after multimodal treatment that included surgery for thoracic outlet syndrome.

Objective:

Though rare, effort thrombosis should be included in the differential diagnosis of throwing athletes with traditional extremity-focused symptoms and in cases involving pulmonary or thoracic complaints. Rapid diagnosis is a critical component of successful treatment.

Coronary Stent Fracture

Coronary stent fracture is a relatively uncommon and rare complication of stent implantation. The reported incidence of stent fracture among drug-eluting stents ranges from 1% to 8%. Since 2003, when the use of drug-eluding stents was approved by the FDA for the treatment of coronary atherosclerosis, a number of retrospective and prospective studies and case reports have been published. We reviewed these publications to determine the incidence, predictors, clinical implications, and different management strategies for drug-eluding stent fracture in the coronary arteries. A review of the literature showed that the risk for stent fracture was higher with right coronary artery location, increased vessel tortuosity and angulation prior to stenting, use of overlapping stents, and use of longer stents. A higher risk of bare metal stent fracture was reported in saphenous vein bypass grafts. The authors also report in this issue in the Department “Case Study” a symptomatic fracture of a sirolimus-eluding Cypher® stent in the mid-left anterior descending artery.

Covered stent application of a repeatedly regrowing iatrogenic subclavian artery pseudoaneurysm at the origin of the vertebral artery

SUMMARY

Formation of an iatrogenic subclavian artery pseudoaneurysm while attempting central venous access through the internal jugular vein is relatively uncommon. However, management of a subclavian artery pseudoaneurysm remains a challenge because of its growing tendency and its relation to the origin of the vertebral artery (VA). We report a strategy for using a covered stent as for the endovascular treatment of a patient with a repeatedly regrowing subclavian artery pseudoaneurysm at the origin of the VA.

Renal Artery Thrombosis Caused by Stent Fracture in a Single Kidney Patient

PURPOSE

To report a case of incomplete expansion, fracture, and thrombosis of a stent in the renal artery.

CASE REPORT

A 47-year-old man with right renal artery occlusion underwent direct stenting of the left renal artery using a balloon-expandable stent. Completion angiography showed satisfactory patency of the vessel although the stent was not fully expanded in its central segment. The patient received 5000 units of heparin during the procedure, but no additional anticoagulant or antiplatelet therapy in the peri/postinterventional period. Twenty-five days later, he presented with acute renal insufficiency and uncontrolled hypertension. Angiography revealed in-stent thrombosis and collateral flow in the distal segment of the left renal artery. He underwent an aortorenal bypass, which salvaged the kidney. The stent, after removal from the vessel, was fractured and not completely expanded.

CONCLUSIONS

Incomplete expansion and fracture of the stent associated with insufficient antiplatelet therapy produced in-stent thrombosis. Collateral flow prevented kidney necrosis.

Elective and emergent endovascular treatment of subclavian artery aneurysms and injuries

PURPOSE

To demonstrate our short and long-term results after transbrachial treatment of subclavian artery aneurysms and injuries with stent-grafts in elective and emergency settings.

METHODS

Ten of 12 consecutive patients (6 men; mean age 63.8 years, range 38-80) were treated electively with commercially prepared endografts delivered via a transbrachial access to repair a subclavian artery aneurysm (n=3) or an injury from a misplaced central venous catheter (n=7). Two patients required emergency treatment for a ruptured atherosclerotic aneurysm in one and an unintentional arterial puncture during placement of a central venous access in the other. Stent-graft patency during follow-up was assessed by physical examination with comparison of brachial blood pressures in all patients; computed tomography angiography (CTA) was performed in available patients.

RESULTS

Successful deployment of stent-grafts with sealing of the lesion was achieved in all cases. There were 2 (17%) procedural complications. One patient developed an access-site hematoma that required surgical revision. The second patient, who had a right subclavian injury, suffered an embolic cerebral infarction. The primary stent-graft patency during follow-up (mean 11.6 months) was 100%. CTA examinations in 7 patients at a mean 18 months showed strut dislocation at the thoracic outlet without luminal narrowing in 1 patient. A 50% intraluminal narrowing due to compression between the clavicle and the first rib occurred in another patient. Six patients with a mean follow-up of 23 months (range 0.3-4.5 years) are still alive with patent stent-grafts.

CONCLUSIONS

Endovascular stent-graft treatment of subclavian artery aneurysms and injuries is a less invasive alternative to surgical repair. Long-term results must still be confirmed in further studies.

Coil embolization combined with carotid-subclavian bypass for treatment of subclavian artery aneurysm

PURPOSE

To report 2 cases of proximal subclavian artery aneurysm treated with carotid-subclavian bypass and coil embolization.

CASE REPORTS

A subclavian artery aneurysm was discovered incidentally during presurgical coronary angiography in 2 men (72 and 63 years of age). Both patients underwent planned carotid endarterectomy, during which a carotid-subclavian bypass was created with a Dacron graft; the distal subclavian artery was also ligated. The aneurysm was completely excluded from the circulation by coil embolization in a separate procedure. The patients were discharged after 3 days with no adverse events. Magnetic resonance angiography at 6 months showed continued aneurysm exclusion in both cases. The patients continue to be well >1 year after treatment.

CONCLUSIONS

Embolization with supraclavicular bypass represents a viable alternative to traditional thoracotomy and subclavian artery reconstruction for treatment of subclavian artery aneurysms.

Emergent axillary artery stent-graft placement for massive hemorrhage from an avulsed subscapular artery

PURPOSE

To report the successful endovascular repair of an acute axillary artery hemorrhage.

CASE REPORT

An 87-year-old woman with Charcot-Marie-Tooth ataxia presented with an enormous shoulder hematoma and clinical signs of exsanguination after a fall. Angiography demonstrated complete avulsion of the right subscapular artery from the axillary artery, and active bleeding into a hematoma of at least 1500 mL. Endovascular repair with a balloon-mounted covered stent-graft was performed percutaneously, which controlled the bleeding and averted surgery. The patient recovered uneventfully and was without signs of recurrent bleeding or ischemia on the 6-month ultrasound examination; she reports no symptoms referable to her upper extremity after 14 months.

CONCLUSIONS

Endovascular repair with stent-grafts is effective in controlling arterial bleeding from supra-aortic vessels even under emergency conditions.

Endovascular stenting for the nutcracker phenomenon

PURPOSE

To present a case highlighting the efficacy of stent implantation for left renal vein (LRV) entrapment, otherwise known as the nutcracker phenomenon.

CASE REPORT

A 17-year-old boy presented with a history of gross hematuria and left flank pain. Magnetic resonance angiography documented compression of the LRV between the superior mesenteric artery and aorta. A Memotherm stent was successfully placed across the LRV to restore adequate luminal flow after a Wallstent failed to adequately span the narrowed segment. Spiral CT angiography at 6 months confirmed LRV patency; the patient remains asymptomatic and free of hematuria at 12 months.

CONCLUSIONS

Endovascular stenting for the nutcracker phenomenon is safe and effective and may represent a valuable approach for lessening the morbidity of surgical procedures.

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

PURPOSE

To compare long-term patency after balloon angioplasty of stenotic or occluded subclavian arteries with and without adjunctive stenting and to identify independent risk factors for restenosis after balloon angioplasty.

METHODS

In a retrospective cohort study, 115 consecutive patients (65 women; mean age 60 years, interquartile range 53-68) who underwent PTA for atherosclerotic subclavian artery obstruction within a 15-year period were included. Among these, 26 (23%) consecutive patients had Palmaz stents routinely implanted since 1996. Follow-up investigation was performed in the year 2000. Patency during the median 44-month follow-up period (interquartile range 18-69 months, minimum 12) was evaluated by oscillography, blood pressure measurement, and color-coded duplex sonography. The predictive value of possible risk factors for restenosis was assessed in a multivariate model controlling for cardiovascular comorbidities and angiographic data.

RESULTS

PTA success was achieved in 98 (85%) patients, 72 (81%) of 89 undergoing angioplasty alone and all 26 with stents. Complete occlusion of the vessel and long lesions (> or = 2 cm) correlated with a lower success rate. One-year patency was 76% in unstented arteries and 95% in stented lesions due to better primary technical success, but at 4 years, the patency rates were 59% in arteries with stents and 68% in arteries without. Long lesions, residual stenosis after PTA, and stent implantation were independent predictors for restenosis after successful intervention.

CONCLUSIONS

Subclavian arterial stent implantation is associated with better 1-year patency than PTA due to improved technical success, but intermediate and long-term outcomes are less favorable, as instent restenosis frequently occurs.

Endovascular repair of occluded subclavian arteries following penetrating trauma

PURPOSE

To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma.

CASE REPORTS

Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients.

CONCLUSIONS

Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Endovascular repair of latrogenic subclavian artery perforations using the Hemobahn stent-graft

PURPOSE

To report the use of a new self-expanding endograft for percutaneous treatment of iatrogenic subclavian artery perforations.

CASE REPORTS

The subclavian artery of 2 patients was inadvertently cannulated during percutaneous attempts to implant a permanent pacemaker in one and catheterize the subclavian vein in the other. Because both patients had serious comorbidities, endovascular repair of the subclavian perforations was performed using the Hemobahn endograft, a nitinol stent covered internally with expanded polytetrafluoroethylene. The endoprostheses were successfully deployed via an ipsilateral brachial artery access. No signs of endograft occlusion, migration, deformation, or fracture have been observed during follow-up at 12 and 10 months, respectively, in these patients.

CONCLUSIONS

The Hemobahn stent-graft appears well suited to repairing subclavian artery injuries. Longer follow-up will determine if the design of this endograft will resist compression in this vascular location.

Endovascular repair of an innominate artery false aneurysm following blunt trauma

PURPOSE

To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma.

METHODS AND RESULTS

A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months.

CONCLUSIONS

This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.