Endovascular Stenting vs. Extrathoracic Surgical Bypass for Symptomatic Subclavian Steal Syndrome

Long-Term Outcome of Carotid-Subclavian Bypass in the Management of Coronary-Subclavian Steal Syndrome

OBJECTIVE

The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome.

METHODS

This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records.

RESULTS

Nine patients (all males, mean age of 69.1 years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1 months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9 months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft.

CONCLUSION

Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

Endovascular Treatment of Subclavian Artery Occlusion by Surgical Exposure of the Proximal Brachial Artery at the Side of an Arteriovenous Fistula

A 76-year-old man undergoing hemodialysis complained of pain and discoloration of his right finger. The hemodialysis arteriovenous fistula was in the right upper extremity. Ultrasonography showed right subclavian artery occlusion. The lesion could not be approached from the lower extremity and olecranon artery. Thus, we performed the procedure after exposing the proximal brachial artery. We were able to recanalize the subclavian artery and restore blood flow to the right upper extremity. When the lesion is on the side of the arteriovenous fistula and approaching from the lower extremity is difficult, exposure of the proximal brachial artery can be considered.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Coronary subclavian steal syndrome due to thrombosis of the left subclavian artery aneurysm: a case report

Background

Coronary subclavian steal syndrome (CSSS) is an often easily overlooked cause of angina that may occur after a coronary artery bypass graft (CABG) procedure. The onset of CSSS several years after coronary revascularization has been described in case reports, and in the few retrospective reviews that compare the endovascular approach with surgical treatment. Subclavian stenosis can naturally coincide with coronary artery disease and may already be present during the initial CABG.

Case summary

A 59-year-old male with a history of three-vessel disease who had a left internal mammary artery (LIMA) bypass graft, exhibited a gradual worsening of angina that coincided with numbness and impaired function of the left fingers, hand, and arm. Myocardial perfusion imaging showed reversible ischaemia, and coronary angiography suggested a thrombotic lesion proximal to the LIMA ostium. Calcified and partially thrombosed proximal left subclavian artery (LSA) aneurysm was visualized using computed tomography imaging, whereas Doppler ultrasound revealed a partially reversed vertebral flow. The lowest risk treatment was a bypass between the left common carotid artery and the LSA. The procedure was immediately successful, with cessation of symptoms and a favourable medium-term outcome.

Discussion

As no guidelines exist for such cases, the importance of multidisciplinary co-operation in diagnostics and devising a treatment plan is underlined. Moreover, screening for subclavian artery stenosis in CABG candidates should be warranted as part of the initial preoperative assessment.

[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.

Balloon-hooking technique for stabilizing a guiding catheter in tortuous supra-aortic vessel: A case report

Objective: When performing endovascular interventions for supra-aortic vessels, the tortuous vascular anatomy observed in patients with atherosclerotic lesions often limits the ability to maintain a stable guiding catheter position. Here, we report a case of right vertebral artery (VA) stenosis treated with transfemoral stenting and discuss the utility of balloon-hooking technique using partially inflated balloon for stabilizing the balloon guiding catheter (BCG) in the supra-aortic vessel. Case presentation: A 74-year-old man who underwent right carotid artery stenting, coronary artery bypass grafting, and bilateral iliac artery stenting was admitted to our emergency department because of dizziness related to head movement. Computed tomography angiography revealed right VA origin stenosis and left subclavian artery (SA) occlusion. The patient underwent stenting of the right VA. After several unsuccessful cannulation attempts into the right VA through transradial access, transfemoral access was obtained through the left iliac stent. A 9-Fr BGC was navigated into the right SA. The balloon was partially inflated just distal to the first curve of the right SA and used as hook by pulling back until the proximal edge of the balloon was pushed distally by the lesser curvature of the SA, resulting in stabilization of the BGC and successful angioplasty and stent deployment at the VA stenosis. The patient's symptoms resolved completely, without any neurological deficits. Conclusions: Balloon-hooking technique using a partially inflated BGC is feasible for stabilizing the guiding catheter in tortuous supra-aortic vessel.

Subclavian atherectomy and angioplasty for coronary subclavian steal syndrome post CABG

Coronary subclavian steal syndrome is an uncommon complication occurring in patients with coronary artery bypass graft (CABG). We describe a case of a 69-year-old male with a remote history of CABG who presented with exertional left arm pain and angina. Computed Tomographic Angiography of the chest demonstrated a severe left proximal subclavian artery stenosis. The case demonstrates successful application of subclavian atherectomy with use of embolic protective device, alleviating the need of stent, for treatment of Coronary subclavian steal syndrome in patient with remote history of CABG.

Carotid-Vertebral or Carotid-Subclavian Transpositions in Supra-Aortic Steno-Occlusive Diseases When Endovascular Therapy Is Unfeasible or Unsuccessful

Background and purpose

Despite advances in endovascular therapies, some patients experience vertebral artery stenosis or subclavian artery occlusion and may not benefit from less-invasive angioplasty/stenting. This study described 4 cases in which carotid-vertebral transposition (CVT) or carotid-subclavian transposition (CST) was adapted when endovascular treatment was unfeasible or unsuccessful.

Presentation

Case 1: A 65-year-old woman presented with severe stenosis of the right vertebral artery ostium, dysplastic left vertebral artery, and aneurysmal dilatation of proximal right subclavian artery and brachiocephalic trunk. Case 2: A 23-year-woman had severe stenosis at the first portion of left vertebral artery caused by Takayasu's arteritis. Because endovascular intervention was unfeasible, CVTs were performed in cases 1 and 2. Case 3: A 73-year-old man presented with total occlusion of the proximal right subclavian artery and severe stenosis of the right internal carotid artery. Case 4: A 58-year-old man experienced complete occlusion of the left subclavian artery and severe stenosis of the left common carotid artery. Duplex ultrasonography showed reverse flow in the vertebral artery in keeping with vertebral steal syndrome. Endovascular treatment was unsuccessful because the wire did not cross the occlusion of the subclavian artery. CSTs were performed with concurrent ipsilateral carotid endarterectomy in cases 3 and 4.

Conclusion

The present case series demonstrated that CST and CVT were effective treatment modalities for subclavian or vertebral artery lesions. Although endovascular stenting and angioplasty have been advocated as first-line management, CST and CVT should be considered as the remedy when endovascular intervention is unsuccessful or unfeasible.

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.

Combined Transradial and Transfemoral Approach With Ostial Vertebral Balloon Protection for the Treatment of Patients With Subclavian Steal Syndrome

Background: Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1–5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA.

Objective: To assess the safety and feasibility of a novel technique for distal embolic protection using balloon catheters during SA revascularization with a dual transfemoral and transradial access.

Methods: We describe a case series of patients with SSS who underwent SAPTA due to severe stenosis or occlusion of the SA using a combined anterograde/retrograde approach. Transfemoral access to SA was obtained using large bore guide sheaths. Ipsilateral transradial access was obtained using intermediate bore catheters. A Scepter XC balloon catheter was introduced through the transradial intermediate catheter into the ipsilateral VA at the ostium during SAPTA for distal embolic protection.

Results: A total of eight patients with SSS underwent subclavian SAPTA. Four patients had the combined anterograde/retrograde approach. Successful revascularization was achieved in three of them. It was difficult to create a channel in the fourth unsuccessful case due to heavily calcified plaque burden. No peri-operative ischemic events were identified. On follow-up, we demonstrated patency of the stents with resolution of symptoms and without any adverse events.

Conclusion: Subclavian stenting using a combined transradial and transfemoral access with compliant balloon catheters at the vertebral ostium for prevention of distal emboli may represent an alternative therapeutic approach for the treatment of SA stenosis and occlusions.

A Unique Case of STEMI STEALing the Flow

We report a case of a 55-year-old woman with previous coronary artery bypass grafting. She presented with acute ST-segment elevation myocardial infarction secondary to occlusion of the proximal left subclavian artery causing reduced flow in the left internal mammary artery to left anterior descending artery graft. (Level of Difficulty: Intermediate.)

Endovascular Treatment of Chronic Total Occlusion in the Subclavian Artery: A Review of 23 Cases

Objectives and Background: To review technical details and long-term outcomes of endovascular treatment of chronic total occlusion (CTO) of the subclavian artery. Methods: From January 2010 to May 2017, 23 patients (17 male; median age, 65 years) underwent endovascular treatment for CTO of the subclavian artery. All lesions had been diagnosed by duplex scanning or computed tomography angiography before treatment. Sixteen (70.0%) patients had symptoms of vertebrobasilar insufficiency, 6 (26.1%) patients had symptoms of arm ischemia, and 2 (8.7%) patients were asymptomatic. Duplex scanning revealed that 16 patients had grade 3 and 7 patients had grade 2 steal blood flow. After recanalization, lesions were treated by stenting. Patients were followed up at 1, 3, 6, and 12 months after endovascular treatment, and annually thereafter. Results: The overall technical success rate was 91.3% (21/23). The successful recanalization rate of antegrade and retrograde approaches were 68.2% (15/22) and 75.0% (6/8), respectively. The rate of clinical symptom remission was 95.2% (20/21) after treatment. No perioperative death or permanent neurological deficits were observed. One patient had arterial dissection treated by covered stent. The estimate cumulative primary and secondary patency rates at 5 years were 74.6 and 78.8%, respectively. Conclusion: Endovascular treatment is a feasible and safe treatment for CTO lesions of the subclavian artery.

Significance of hemodynamic assessment by pressure wire for endovascular therapy of subclavian steal syndrome

OBJECTIVE

Subclavian steal syndrome results from hemodynamic impairment due to stenosis or occlusion of subclavian artery. Therefore, it is important for subclavian steal syndrome patients to assess hemodynamic status during endovascular therapy.

METHODS

Eleven subclavian steal syndrome patients undergoing endovascular therapy attended this study. Pressure wire was used to measure trans-stenosis pressure difference (ΔP). Digital subtraction angiography, Transcranial Doppler and Electronic sphygmomanometer were introduced to assess stenotic rate, steal grade and inter-arm systolic pressure difference, respectively. Clinical symptoms and restenosis were followed up after endovascular therapy. The associations of ΔP with stenotic rate, inter-arm pressure difference, steal degree, clinic symptoms and restenosis were analyzed in this paper.

RESULTS

Prior to the therapy, ΔP moderately correlated with stenotic rate (r = 0.757, p = 0.007) and inter-arm pressure difference (r = 0.701, p = 0.016). ΔP was ≥6 mmHg in all patients, and 6-9 mmHg for grade 1 steal and ≥10 mmHg for grade 2 and 3 steals. After the therapy, all patients had technique success, and 10 patients had clinic success, and 1 patient appeared restenosis. ΔP was ≤3 mmHg and steal disappeared in the patients with clinical success. ΔP was 18 mmHg and grade 3 steal still existed in one patient without clinical success. One patient with 1 mmHg of ΔP after therapy appeared restenosis in the follow-up.

CONCLUSION

The trans-stenosis pressure difference is closely related to steal degree and clinical symptoms. The measurement of hemodynamic status by pressure wire is very useful to guide endovascular therapy in subclavian steal syndrome patients. However, the restenosis may still occur, even though the hemodynamic impairment is improved.

Percutaneous Antegrade and Retrograde Endovascular approach to Symptomatic High-Grade Subclavian Artery Stenosis: Technique and Follow-Up

Background and Purpose:

Angioplasty and stenting of the subclavian artery have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates. Different antegrade or retrograde endovascular catheter-based approaches are used. Nowadays, endovascular therapy has taken over open surgical techniques in subclavian artery disease. The purpose of this study was to determine safety, efficacy, and midterm clinical and radiological outcome of the endovascular treatment with special focus on the different technical approaches in subclavian artery disease.

Materials and Methods:

Between 2014 and 2017, 11 patients (10 men, 1 woman) with symptomatic high-grade stenosis (90%–100%) of the subclavian artery were treated with endovascular treatment. Their mean age was 51.3 years (range, 32-61 years). Mean angiographic and clinical follow-up was 22.5 months (range, 5-44 months). Clinical follow-up was performed at hospital discharge and routine follow-up was performed at 1, 3, 12 months, and 6 monthly thereafter. In all 11 patients, a percutaneous approach was used successfully. In eight patients, the lesions were accessed retrogradely through a brachial artery puncture.

Results:

Acute success rate was 100%. There were no significant peri-procedure complications. At the latest clinical follow-up (mean of 22.5 months), all patients showed a good outcome with a restenosis rate of 18.2% including a patient with Takayasu arteritis.

Conclusion:

Percutaneous antegrade and retrograde stenting of high-grade subclavian artery stenosis is a viable less invasive alternative to open bypass surgery with good midterm clinical results and patency rates.

Outcomes of carotid-subclavian bypass performed in the setting of thoracic endovascular aortic repair

BACKGROUND

Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR). However, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass in this clinical setting. As such, this study sought to define the early and late outcomes associated with this procedure.

METHODS

Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including cervical plexus nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications.

RESULTS

Of 579 consecutive patients undergoing TEVAR during this time interval, 112 patients (19%) underwent concomitant carotid-subclavian bypass. The cohort was 38% female (n = 43), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [95.5%]), with a minority being reversed saphenous vein (n = 4 [3.6%]) or Dacron (n = 1 [0.9%]) grafts. The bypass procedure was done concurrently at the time of TEVAR in 91% (n = 102) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 29% (n = 33). These complications included phrenic nerve palsy in 25% (n = 27), recurrent laryngeal nerve palsy in 5% (n = 6), axillary nerve palsy in 2% (n = 2), and neck hematoma requiring re-exploration in 1% (n = 1) of patients. The 30-day in-hospital all-cause mortality rate was 5% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 106), follow-up imaging of the bypass graft was available in 87% (n = 92) of patients. Actuarial primary graft patency was 97% at 5 years. There were three patients (3%) with bypass graft occlusions, two of which were clinically silent and detected on follow-up imaging. The third was detected because of symptoms of subclavian steal and required repeated revascularization. Two patients (2%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention.

CONCLUSIONS

Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely higher than is generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as "gold standard" comparison data for emerging branch graft devices.

Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease

BACKGROUND

Endovascular treatment offers an alternative, less invasive approach to open repair for subclavian artery atherosclerotic disease (SAAD). However, only few studies compared the outcomes of both strategies in the long run. This study reports on the performance of endovascular and surgical revascularization for SAAD.

METHODS

A retrospective review was conducted on patients treated for SAAD at two institutions between January 1998 and December 2015. Primary outcome of this study was the composite endpoint of reintervention-free survival (RFS) defined as time to reintervention and/or death from any cause. Secondary endpoints included primary patency (PPR) and secondary patency (SPR) rates as well as overall survival and time to reintervention.

RESULTS

Surgical treatment was the preferred treatment option in 27 (25%) patients, while 83 (75%) patients underwent primary stent therapy. The median follow-up was 87 months (interquartile range [IQR]: 38 to 151) in the surgical group and 27 (IQR: 12 to 59) in the endovascular (P=0.0001). Severe arterial wall calcification was more commonly observed in the surgical arm (P<0.0001), while mild and moderate calcification in the endovascular (P=0.0004 and P=0.014). Vessel occlusion was more frequent among patients treated surgically (100% vs. 34%, P<0.0001). At 98 months RFS was significantly higher after surgical treatment (95% vs. 54%, HR: 8.4, 95% CI: 3.9 to 18.1, P=0.0002). Although overall survival did not differ significantly between the two groups (HR: 4.28, 95% CI: 0.86 to 21.22, P=0.093), open repair was associated with reduced reintervention rate (HR: 12.04, 95% CI: 4.98 to 29.12, P=0.001). The PPR at 98 months following surgical and endovascular therapy amounted to 96% and 65% (HR: 12.87, 95% CI: 5.44 to 30.44, P=0.0008) respectively. No significant difference was observed regarding the SPR between the two groups (100% vs. 95%, P=0.090).

CONCLUSIONS

Surgical treatment was associated in this cohort with increased patency and a significant reduction of reinterventions compared to the endovascular approach.

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.

Review of coronary subclavian steal syndrome

The clinical benefits of using the left internal mammary artery (LIMA) to bypass the left anterior descending artery are well established making it the most frequently used conduit for coronary artery bypass surgery (CABG). Coronary subclavian steal syndrome (CSSS) occurs during left arm exertion when (1) the LIMA is used during bypass surgery and (2) there is a high grade (≥75%) left subclavian artery stenosis or occlusion proximal to the ostia of the LIMA resulting in "stealing" of the myocardial blood supply via retrograde flow up the LIMA graft to maintain left upper extremity perfusion. Although CSSS was once thought to be a rare phenomenon, its prevalence has been underestimated and is becoming increasingly recognized as a serious threat to the success of CABG. Current guidelines are lacking on recommendations for screening of subclavian artery stenosis (SAS) pre- and post-CABG. We hope to provide an algorithm for SAS screening to prevent CSSS in internal mammary artery bypass recipients and review treatment options in the percutaneous era.

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.

Multiterritory Atherosclerosis and Carotid Intima-Media Thickness as Cardiovascular Risk Predictors After Percutaneous Angioplasty of Symptomatic Subclavian Artery Stenosis

OBJECTIVES

To identify independent predictors of cardiovascular events among patients with subclavian artery stenosis.

METHODS

Two hundred eighteen consecutive patients with subclavian artery stenosis referred to angioplasty were examined for coexistent coronary, renal, or lower extremity artery stenosis of 50% or greater. Initial carotid intima-media thickness and internal carotid artery (ICA) stenosis were assessed. Intima-media thickness was reassessed in 108 randomly chosen patients to evaluate the change over time. The incidence of cardiovascular death, myocardial infarction (MI), ischemic stroke, and symptomatic lesion progression was recorded.

RESULTS

The patients included 116 men and 102 women (mean age ± SD, 62.1 ± 8.4 years). Isolated subclavian artery stenosis and involvement of 1, 2, and 3 or 4 other territories with stenosis of 50% or greater were found in 46 (21.1%), 83 (38.1%), 55 (25.2%), and 34 (15.6%) patients, respectively. Internal carotid artery stenosis of 50% or greater (relative risk [RR], 1.54; 95% confidence interval [CI], 1.39-1.70; P < .001) and initial intima-media thickness (RR, 1.16; 95% CI, 1.05-1.28; P = .005) were identified as independent markers of multiterritory atherosclerosis. The optimal intima-media thickness cutoff for atherosclerosis extent was 1.3 mm (sensitivity, 75.6%; specificity, 76.1%). During follow-up of 57 ± 35 months, cardiovascular death, MI, and ischemic stroke occurred in 29 patients (13.3%). Those patients had significantly higher intima-media thickness progression (+0.199 ± 0.57 versus +0.008 ± 0.26 mm; P = .039) and more widespread initial atherosclerosis (mean territories, 1.8 ± 1.1 versus 1.3 ± 1.1; P = .042). Independent predictors of cardiovascular death, MI, ischemic stroke, and lesion progression were coronary artery disease (RR, 1.32; 95% CI, 1.10-1.58; P = .003) and intima-media thickness progression (RR, 1.22; 95% CI, 1.02-1.46; P = .033; sensitivity, 75.0%; specificity, 61.8%).

CONCLUSIONS

In patients with symptomatic subclavian artery stenosis, baseline carotid intima-media thickness and ICA stenosis of 50% or greater are associated with multiterritory atherosclerosis, whereas intima-media thickness progression is associated with the risk of cardiovascular events.

Resolution of ischemic symptoms after percutaneous angioplasty for a symptomatic subclavian artery stenosis

OBJECTIVE

A minor part of patients with subclavian or innominate artery occlusive disease (subclavian artery stenosis [SAS]) experience symptoms of vertebrobasilar insufficiency, upper extremity exertional ischemia (UEEI), or cardiac ischemia owing to subclavian-coronary steal (SCS) in some instances. The study aimed to assess the impact of percutaneous transluminal angioplasty (PTA) of symptomatic SAS on symptom resolution and to determine factors related with SAS recurrence.

METHODS

Symptom resolution and incidence of restenosis (RS) were evaluated for up to 15 years in patients who had undergone successful PTA of SAS.

RESULTS

The study group comprised 232 consecutive subjects after successful PTA of SAS (61.9 ± 8.4 years old 53.4% men). The mean follow-up time was 101 ± 40 months (range, 5-188 months). One month after PTA, 85.4% of the study participants were free from dizziness, 94.4% from imbalance, 97.1% from visual disturbances, 97.8% from syncope, 98.7% from UEEI, and 100% from SCS. RS was found in 37 patients (15.9%) in long-term observation. UEEI, dizziness, imbalance, and SCS were significantly more frequent in patients with SAS recurrence, as compared with patients with patent artery (65.9% vs 3.1% [P < .001] 63.4% vs 19.4% [P < .001]; 26.8% vs 9.4% [P = .005]; and 100% vs 15.4% [P = .018], respectively). Smaller stent diameter (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79-0.96; P = .004), implantation of ≥2 stents for a lesion (OR, 1.15; 95% CI, 1.05-1.26; P = .003), concomitant stenosis in the carotid or vertebral artery (OR, 1.10; 95% CI, 1.01-1.21; P = .036), high-sensitivity C-reactive protein level (OR, 1.20; 95% CI, 1.09-1.31; P < .001), and high-density lipoprotein level (OR, 0.91; 95% CI, 0.82-0.98; P = .021) were associated independently with risk of RS, whereas recurrence of UEEI (relative risk, 1.71; 95% CI, 1.55-1.90; P < .001), dizziness (OR, 1.26; 95% CI, 1.14-1.39; P < .001), limb paresthesia (OR, 1.14; 95% CI, 1.04-1.25; P = .005), and angina in subjects after coronary artery bypass grafting (OR, 1.11; 95% CI, 1.01-1.21; P = .024) were associated with RS/SAS progression after PTA.

CONCLUSIONS

Angioplasty of SAS leads to symptom resolution in most patients. UEEI, dizziness, and angina recurrence are predictors of RS or SAS progression; high-sensitivity C-reactive protein, smaller stent diameter, and number of implanted stents predict RS.

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.

Successful Treatment of a Subclavian Artery Stenosis With a Coronary Bioresorbable Vascular Scaffold

PURPOSE

To report the use of a coronary bioresorbable vascular scaffold to treat subclavian artery disease.

CASE REPORT

A 58-year-old man was admitted for left subclavian steal syndrome. Angiography showed significant left subclavian stenosis in proximity to the ostium of the left vertebral artery. To maximize radial support and minimize restenosis risk while avoiding the chance of vertebral compromise, a coronary bioresorbable vascular scaffold (3.5×28 mm) was implanted after predilation. The device was postdilated with a 1.0-mm oversized balloon, with immediate improvement in hemodynamics and symptoms. Two-year clinical and imaging follow-up confirmed vessel patency.

CONCLUSION

This clinical vignette highlights the flexibility and potential of bioresorbable devices for endovascular specialists and calls for further development and use of this innovative technology.

Perioperative and Long-term Outcomes of Endovascular Treatment for Subclavian Artery Disease From a Large Multicenter Registry

Purpose: To investigate the perioperative and long-term outcomes of endovascular therapy (EVT) for subclavian artery disease in a large-scale multicenter study. Methods: The study analyzed the outcomes from a multicenter retrospective registry (SubClavian Artery disease treated with endovascuLar therapy; muLticenter retrOsPective registry: SCALLOP) of 718 consecutive patients with upper extremity artery disease who underwent EVT between January 2003 and December 2012 at 37 Japanese cardiovascular centers. Of the 718 patients enrolled in the registry, 162 patients were excluded, leaving 553 patients (mean 70±7 years, range 41–91; 405 men) who underwent primary EVT for de novo subclavian artery disease (560 arms). Results: Procedure success was achieved in 96.8% (100% for stenoses, 91% for total occlusions). The perioperative complication rate was 9.2%. Stroke was found in 1.8%, with ipsilateral posterior infarction accounting for 0.9%. The 30-day mortality was 0.7%. The mean follow-up was 39±24 months. Primary patency estimates were 90.6%±1.3%, 83.4%±1.8%, and 80.5%±2.2% at 1, 3, and 5 years, respectively. There was no significant difference in primary patency between stenotic and occlusive lesions. Secondary patency estimates were 99.2%±0.4%, 98.2%±0.6%, and 97.7%±0.8% at 1, 3, and 5 years, respectively. The respective overall survival rates were 94.6%±1.0%, 86.8%±1.7%, and 79.0%±2.4%. There were 86 deaths during follow-up, of which half were due to cardiovascular causes. On multivariate analysis, critical hand ischemia (hazard ratio [HR] 4.6, 95% CI 2.06 to 10.2, p<0.001), cerebrovascular disease (HR 1.9, 95% CI 1.14 to 3.06, p=0.01), current smoking (HR 1.8, 95% 1.14 to 2.79, p=0.01), and lesion length (in 1-cm increments; HR 1.02, 95% CI 1.00 to 1.04, p=0.03) were negative independent predictors of primary patency, while IVUS use (HR 0.6, 95% CI 0.30 to 0.96, p=0.04) was a positive predictor of primary patency. Conclusion: Primary angioplasty/stenting for subclavian artery disease afforded acceptable outcomes in terms of perioperative complications and long-term patency.

Mechanical thrombectomy in proximal subclavian artery in-stent occlusion

PURPOSE

Mechanical thrombectomy is an established tool for endovascular therapy of acute/chronic in-stent occlusions of the lower extremities, especially for the superficial femoral artery. The authors report the use of the Rotarex catheter system for an in-stent proximal subclavian occlusion.

CASE PRESENTATION

A 51-year-old female patient with previous multiple attempts at left subclavian revascularization; primary endovascular stenting at the origin of the subclavian artery occluded at 3 months, and a carotid-subclavian bypass was placed distally to the stent. After 6 months from the first treatment, the patient was readmitted with an acute left arm ischemia and full occlusion of the bypass was confirmed at computed tomography angiography. An anterograde thrombectomy for in-stent restenosis, together with PTA with a drug-eluting balloon was performed in the subclavian artery with confirmed patency at 6 months.

CONCLUSION

Mechanical thrombectomy together with drug-eluting balloon PTA for in-stent occlusion or restenosis of the subclavian artery could be a promising procedure with a lower invasivity and risk with respect to surgical options.

Coronary-subclavian steal syndrome: percutaneous approach

Coronary subclavian steal syndrome is a rare ischemic cause in patients after myocardial revascularization surgery. Subclavian artery stenosis or compression proximal to the internal mammary artery graft is the underlying cause. The authors present a clinical case of a patient with previous history of non-ST elevation myocardial infarction, triple coronary bypass, and effort angina since the surgery, with a positive ischemic test. Coronary angiography revealed a significant stenosis of the left subclavian artery, proximal to the internal mammary graft.

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.