Percutaneous and open retrograde endovascular stenting of symptomatic high-grade innominate artery stenosis: technique and follow-up

Color Duplex Ultrasonography for the Evaluation of Innominate, Subclavian, and Common Carotid Artery Stenosis

OBJECTIVE

This study aimed to validate the efficiency of Doppler ultrasonography for predicting the innominate, subclavian, and common carotid artery stenosis.

METHODS

This retrospective multicenter study between 2013 and 2022 enrolled 636 patients who underwent carotid Doppler ultrasonography and subsequent digital subtraction angiography. And 58 innominate artery stenosis, 147 common carotid artery stenosis, and 154 subclavian artery stenosis were included. The peak systolic velocity at innominate, subclavian, and common carotid artery, and velocity ratios of innominate artery to common carotid artery, innominate artery to subclavian artery, and common carotid artery to internal carotid artery were measured or calculated. The threshold values were determined using receiver operating characteristic analysis.

RESULTS

The threshold values of innominate artery stenosis were peak systolic velocity >206 cm/s (sensitivity: 82.8%; specificity: 91.4%) to predict ≥50% stenosis and >285 cm/s (sensitivity: 89.2%; specificity: 94.9%) to predict ≥70% stenosis. The threshold values of common carotid artery stenosis were peak systolic velocity >175 cm/s (sensitivity: 78.2%; specificity: 91.9%) to predict ≥50% stenosis and >255 cm/s (sensitivity: 87.1%; specificity: 87.2%) to predict ≥70% stenosis. The threshold values of subclavian artery stenosis were peak systolic velocity >200 cm/s (sensitivity: 68.2%; specificity: 84.4%) to predict ≥50% stenosis and >305 cm/s (sensitivity: 57.9%; specificity: 91.4%) to predict ≥70% stenosis.

CONCLUSIONS

Symptomatic patients with ultrasonic parameters of velocity at innominate artery ≥206 cm/s, velocity at common carotid artery ≥175 cm/s, or velocity at subclavian artery ≥200 cm/s need to be considered for further verification and whether revascularization is necessary.

Systematic Review and Meta-Analysis of the Outcome of Different Treatments for Innominate Artery Stenosis or Occlusion

The present study reported the outcomes of different treatments for innominate artery (IA) atherosclerotic stenosis or occlusion. We performed a systematic review of the literature (4 database searched; last search February 2022), including articles with ≥5 patients. We performed meta-analyses of proportions for different postoperative outcomes. Fourteen studies were included (656 patients; 396 underwent surgery, 260 endovascular procedures). IA lesions were asymptomatic in 9.6% (95% CI 4.6-14.6). Overall estimated technical success (TS) rate was 91.7% (95% CI 86.9-96.4); weighted TS rate was 86.8% (95% CI 75-98.6) in the surgical group (SG), 97.1% (95% CI 94.6-99.7) in the endovascular group (EG). Postoperative stroke in SG was 2.5% (95% CI 1-4.1) and 2.1% in EG (95% CI .3-3.8). Overall, 30-day occlusion was estimated .9% (95% CI 0-1.8) in SG and .7% (95% CI 0-1.7) in EG. Thirty-day mortality was 3.4% (95% CI .9-5.8) in SG and .7% (95% CI 0-1.7) in EG. Estimated mean follow-up after intervention was 65.5 months (95% CI 45.5-85.5) in SG and 22.4 months (95% CI 14.72-30.16) in EG. During follow-up, restenosis in SG were 2.8% (95% CI .5-5.1) and 16.6% (95% CI 5- 28.1) in EG. In conclusion, the endovascular approach seems to offer good short to mid-term outcomes, but with a higher rate of restenosis during follow-up.

Limb shaking transient ischemic attack secondary to innominate artery stenosis

Limb shaking transient ischemic attack is a rare disease manifestation typically caused by carotid stenosis but rarely caused by flow-limiting lesions involving more proximal vasculature. We demonstrate a case of limb shaking transient ischemic attack secondary to innominate stenosis in a 69-year-old woman who presented after a left leg shaking spell that caused her to fall and fracture her ipsilateral tibia. She did not experience changes in mentation and did not show any evidence of a postictal period. After receiving a comprehensive workup, she successfully underwent revascularization with innominate artery stenting. Continuous retrograde aspiration with the Enroute system (Silk Road Medical) and carotid clamping were used for embolic protection.

Endovascular Treatment for Subclavian Artery Stenosis and Occlusion: A Single-Center Retrospective Study

BACKGROUND

Subclavian artery stenosis and occlusion are common arterial diseases in the upper extremities, with atherosclerosis being the main cause. Endovascular treatment has emerged as a promising alternative to open surgical repair, but data are limited. This study aimed to evaluate the safety and effectiveness of endovascular procedures in the treatment of subclavian artery lesions at a tertiary vascular center in Vietnam.

METHODS

A retrospective analysis was conducted on patients who underwent endovascular treatment for symptomatic subclavian artery stenosis or occlusion between October 2013 and April 2022. Clinical characteristics, procedural details, short- and long-term outcomes, and patency rates were assessed.

RESULTS

Twenty-five patients were included in the study, with a mean age of 56.8 years. The majority of patients had risk factors for atherosclerosis, and all presented with symptoms related to subclavian artery disease. The endovascular procedures were successful in 96% of cases, with a low complication rate of 8%. During a median follow-up of 43 months, the overall patency rate was 92% at three years.

CONCLUSION

Endovascular treatment of subclavian artery stenosis and occlusion is a safe and effective option, with excellent long-term patency rates. These findings support the use of percutaneous revascularization as the first-line therapy, particularly in experienced centers. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.

Case report: A hybrid open and endovascular approach for repairing a life-threatening innominate artery dissection using the simultaneous kissing stent technique

Managing acute innominate artery (IA) dissection associated with severe stenosis is challenging due to its rarity, possible complex dissection patterns, and compromised blood flow to the brain and upper extremities. This report describes our treatment strategy for this challenging disease using the kissing stent technique. A 61-year-old man had worsening of an acute IA dissection secondary to an extension of a treated aortic dissection. Four possible treatment strategies for kissing stent placement were proposed based on different approaches (open surgical or endovascular) and accesses (trans-femoral, trans-brachial, or trans-carotid access). We chose to place two stents simultaneously via a percutaneous retrograde endovascular approach through the right brachial artery and a combined open surgical distal clamping of the common carotid artery with a retrograde endovascular approach through the carotid artery. This hybrid approach strategy highlights the three key points for maintaining safety and efficacy: (1) good guiding catheter support is obtainable through retrograde, rather than antegrade, access to the lesion, (2) concomitant cerebral and upper extremity reperfusion is guaranteed by placing kissing stents into the IA, and (3) peri-procedural cerebral emboli are prevented by surgical exposure of the common carotid artery with distal clamping.

Transfemoral subclavian artery stenting through a shaped guiding catheter without pull-through technique: A case report

Transfemoral subclavian artery stenting can be challenging unless the placement of the guiding catheter is secured. Herein, we present a patient with subclavian artery stenosis treated with endovascular stenting using a shaped guiding catheter. A 79-year-old woman was admitted to our department because of a cold sensation and numbness of her left arm. Computed tomography revealed stenosis of the left subclavian artery (SA), located just proximal to the ostium of the left vertebral artery (VA). Doppler ultrasound showed reverse flow in the left VA. We planned to stent for the SA stenosis under the balloon protection of the left VA. The balloon protection device was easily navigated into the left VA through brachial access. After that, a self-expandable stent was successfully placed from just proximal to the VA origin to the ostium of the SA using a highly stable shaped guiding catheter. The patient recovered from the symptoms and was discharged 4 days after the procedure. The high stability of the shaped guiding catheter is advantageous during endovascular treatment of the subclavian artery.

Cerebral protection during retrograde brachiocephalic artery stenting using a single filter and increased subclavian steal phenomenon: illustrative case

BACKGROUND

Cerebral protection during brachiocephalic artery (BCA) stenting is important. However, the maneuver is sometimes challenging because both the internal carotid artery (ICA) and vertebral artery (VA) should be protected. Herein, the authors present an alternative cerebral protection technique involving filter protection for the ICA and hemodynamic protection for the VA during retrograde BCA stenting.

OBSERVATIONS

A 64-year-old man with a thoracic aortic aneurysm presented with cold sensation and numbness in his right arm due to BCA stenosis. Endovascular stenting under cerebral protection was planned. Cerebral protection was attempted through the brachial access. Despite the successful placement of the filter in the ICA, selective catheterization of the VA failed. Furthermore, repeated transfemoral catheterization of the BCA was unsuccessful. Concerning a thoracic aortic aneurysm injury, the authors performed retrograde BCA stenting using a transbrachial approach. Hemodynamic protection of the VA was provided by increasing the subclavian steal phenomenon that resulted in successful recanalization of the BCA.

LESSONS

Retrograde BCA stenting performed while protecting the ICA with a filter and the right VA by increasing the subclavian steal phenomenon was successful. This simple technique is feasible, especially in patients with steno-occlusive lesions of the BCA concurrent with the dominant vertebra/vertebral collateral pathway.

Intravascular lithotripsy in calcified subclavian and innominate peripheral artery disease: A single centre experience

BACKGROUND

Intravascular lithotripsy (IVL) is a novel tool for the treatment of calcified vascular stenosis. Recently, IVL has been successfully used for modification of calcified plaque in coronary and lower extremity peripheral arteries with promising results. However, experience in subclavian and innominate peripheral arterial disease is limited. This study aims to report our initial experience of IVL use in calcified subclavian and innominate vasculature.

METHODS

This was a retrospective review of all the cases of IVL performed in subclavian and innominate arteries at the Miriam Hospital, Providence, between January 2019 and May 2020. Data on the baseline and procedural characteristics were collected. The primary endpoint was procedural success defined as residual stenosis of <20% after stenting. Other endpoints of interest were; 1) procedural complications, including dissections, perforations, abrupt closure, slow or no-reflow, thrombosis, and distal embolization; 2) in-hospital major adverse cardiac events (MACE) defined as a composite of death, myocardial infarction, or stroke/transient ischemic attack.

RESULTS

A total of 7 patients with 13 lesions undergoing IVL were included. Of these, 5 (71%) were women, the mean age was 74.6 ± 12.9, and the mean BMI was 25.1 ± 6.7. IVL was successfully delivered to all the target lesions with a mean 252.9 ± 54.4 pulses delivered per patient. Procedural success was achieved in 100% of the treated lesions. No procedure-related complications or in-hospital MACE occurred in any of the patients.

CONCLUSIONS

In this single-center retrospective analysis, IVL facilitated acute procedural success without any procedural complications in severely calcified stenoses of the subclavian and innominate vasculature. Larger studies with an active comparator and longer follow-up are needed to establish the relative efficacy and safety of IVL use in this vascular bed.

Endovascular Stent Grafting for Recurrent Strokes Due to Fragile Innominate Artery Plaque: A Case Report

Here we describe a case of recurrent ischemic strokes due to fragile innominate artery plaque successfully treated using endovascular stent grafting. An 80-year-old man presented with a history of recurrent strokes that were refractory to medical treatment. Computed tomography and magnetic resonance images of the thorax revealed a gross intramural plaque in the innominate artery. He was successfully treated using endovascular stent grafting. An AFX stent graft device was used to prevent further embolic strokes. The AFX stent graft has a unique endoskeleton design with a thin-walled expanded polytetrafluoroethylene fabric—known as active sealing structure—attached to the implant. Postoperatively, the patient has experienced no recurrent strokes in over 2 years of follow-up. The stent grafting procedure could be an optimal treatment option for treating fragile innominate artery plaques.

Aorto-innominate artery bypass for migrated stent

We report a case of a 64-year-old female who first presented with a transient ischemic attack in 2007 due to an innominate artery stenosis, which indicated an endovascular stent placement. In 2008, she presented with recurrence of symptoms and was diagnosed with in-stent restenosis alongside an unusual occurrence of retrograde migration into the ascending aortic arch. We performed an aorto-innominate bypass through a median sternotomy. The patient was discharged without any complications thereafter, and the graft has shown excellent patency. As of 2019, the patient remains well.

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.

Stenting for Innominate Artery Stenosis Under Double-Filter Protection of the Anterior and Posterior Circulation via the Right Brachial Artery

Several protocols for angioplasty and stenting for stenosis of an innominate artery (IA) are reported, but the protocols are sometimes complicated and have disadvantages. We report a case of IA stenosis presenting ischemic symptoms in a 58-year-old woman. Stenting for the IA stenosis was performed through the right femoral artery. The cerebral protection was placed via the right brachial artery, with a filter at the right internal carotid artery and another filter at the right vertebral artery. The symptomatic IA stenosis was resolved without any complications. Regardless of the direction of blood flow, simultaneous protection of both the anterior and posterior cerebral circulation is necessary during IA stenting. Double-filter protection can provide excellent cerebral protection during an IA stenting procedure.

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

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

A Case of Critical Calcified Innominate Artery Stenosis Successfully Treated With the Shockwave Lithoplasty

Purpose:

The Shockwave Lithoplasty System represents a novel technology combining a balloon angioplasty catheter with the use of sound waves. Evidences suggest that it is a reliable tool to overcome calcified stenosis in both peripheral and coronary arteries. Here, we describe the case of a patient with calcified innominate artery stenosis successfully treated with the Shockwave Lithoplasty System.

Case Report:

A 78-year-old woman with hypertension, and dyslipidemia, came to our observation for dizziness. Instrumental examinations showed critical calcified stenosis of the innominate artery. The lesion was successfully treated with the Shockwave Lithoplasty System and subsequent stent apposition. Final angiography demonstrated excellent position of the stent, good wall apposition, and confirmed patency of the right common and right vertebral artery origins.

Conclusion:

Our clinical experience demonstrates that Lithoplasty is safe and effective also for the treatment of supra-aortic vessels.

Endovascular Therapy for the Steal Phenomenon due to the Innominate Artery Severe Stenosis and Bilateral Internal Carotid Artery Severe Stenosis

BACKGROUND

Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery.

CASE REPORT

A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively.

DISCUSSION

For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery.

CONCLUSIONS

Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial artery.

Open retrograde endovascular stenting for left common carotid artery dissection secondary to surgical repair of acute aortic dissection: a case report and review of the literature

A 30-year-old male presented with an acute aortic artery dissection (Stanford type A) and underwent total arch replacement using a stented elephant trunk technique. One month later, the patient developed dissections in the innominate and left common carotid artery (CCA). The innominate artery dissection caused occlusion in the right internal carotid artery (ICA) and a major stroke. Dissection of the left CCA progressed and extended to the bifurcation site. Antegrade access for a left carotid intervention was deemed as difficult because of the previously implanted stent and the additional risks of embolic events and dissection enlargement. Hybrid procedures combining left carotid bifurcation exposure and retrograde endovascular stenting were successfully completed. This report is a rare case of retrograde endovascular reconstruction for the left CCA dissection following surgical repair of an aortic artery dissection. Here, we also review previous cases of iatrogenic carotid dissections following surgical intervention.

Endovascular stenting of symptomatic innominate artery stenosis under distal balloon protection of the internal carotid and vertebral artery for cerebral protection: a technical case report

The use of cerebral protection devices in endovascular treatment for innominate artery (IA) stenosis is not well established. We describe a novel technique for cerebral protection during endovascular stenting of symptomatic IA stenosis. An 82-year-old man presented with acutely scattered brain infarction by artery-to-artery embolism due to IA stenosis. Endovascular treatment for symptomatic IA stenosis was planned to prevent recurrent attacks. Endovascular stenting for IA stenosis via the right femoral artery approach was performed under simultaneous distal balloon protection of the right internal carotid artery (ICA) and vertebral artery (VA) via the right brachial artery approach. Successful treatment of symptomatic IA stenosis was achieved with no complications. The technique with simultaneous distal balloon protection of the ICA and VA provided excellent cerebral protection in stenting of IA stenosis.