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Management of subclavian artery in-stent restenosis Anil Verma, John P Reilly and Christopher J White Vasc Med 2013 18: 350 originally published online 30 October 2013 DOI: 10.1177/1358863X13509129 The online version of this article can be found at: http://vmj.sagepub.com/content/18/6/350
Published by: http://www.sagepublications.com
On behalf of:
Society for Vascular Medicine
Additional services and information for Vascular Medicine can be found at: Email Alerts: http://vmj.sagepub.com/cgi/alerts Subscriptions: http://vmj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 29, 2013 OnlineFirst Version of Record - Oct 30, 2013 What is This?
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
09129
VMJ18610.1177/1358863X13509129Vascular MedicineVerma et al.
Case Report
Management of subclavian artery in-stent restenosis
Vascular Medicine 18(6) 350–353 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X13509129 vmj.sagepub.com
Anil Verma, John P Reilly and Christopher J White
Abstract Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause a significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart. An endovascular approach with primary stenting or provisional stenting has become the primary modality of revascularization of subclavian artery stenosis. In-stent restenosis can be treated with percutaneous transluminal angioplasty or repeat stenting and although stents offer superior long-term patency over balloon angioplasty alone for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Here we describe a case of subclavian in-stent restenosis treated with just balloon angioplasty and demonstrate that provisional stenting with angioplasty alone when the percutaneous transluminal angioplasty results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis. Keywords peripheral vascular diseases; restenosis; stenosis; stents; subclavian artery
Background Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart.1 Primary stenting or provisional stenting (i.e. stenting after failed or suboptimal balloon angioplasty) has become the primary modality of revascularization for subclavian and brachiocephalic arteries because of a high clinical success rate and a lower rate of procedural complications as compared to open surgery.2,3 Endovascular revascularization of atherosclerotic subclavian stenosis with stenting is associated with a technical success rate of 92% to 100% with 2–5-year patency rates ranging from 77% to 89%,4,5 comparable to surgery. Stenting is preferred over percutaneous transluminal angioplasty (PTA) alone because of the uncertain longterm patency and high failure rate of PTA when treating occlusions. In-stent restenosis can be treated with PTA or repeat stenting but there is a paucity of comparative data regarding how best to treat subclavian artery in-stent restenosis. Paclitaxel-coated balloon angioplasty,6 excimer laser debulking,7 stent grafting,8 drug-coated stents9 and brachytherapy10 have been used in the treatment of femoropopliteal in-stent restenosis with variable results, but the role of each of these technologies in the treatment of subclavian artery in-stent restenosis is unknown.
Case report The patient is a 59-year-old woman who presented to our clinic with symptoms of left arm claudication with minimal
arm activity. She was treated with bilateral subclavian artery stents about 10 years previously. She has a history of hypertension, hyperlipidemia and coronary artery disease with coronary artery bypass surgery using a left internal mammary arterial conduit to the left anterior descending artery. She currently denies angina pectoris. She continues to smoke and has a history of peripheral arterial disease with common iliac artery stenosis treated with bilateral stents. She has a past history of ischemic stroke with extensive aortic arch atheroma identified on transesophageal echocardiography. On physical examination, systolic blood pressure was 50 mmHg greater in the right arm compared to the left arm. Magnetic resonance angiography (MRA), performed to investigate symptoms of stroke, demonstrated a possible near occlusion of the left subclavian artery ostium or an artifact (Figure 1). The utility of the MRA may be limited due to the void artifact caused by the metal stent. The MRA report was unreliable due to the metal artifact and thus the patient was taken to the catheterization Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, USA Dr Scott Kinlay was the guest editor for this article. Corresponding author: Christopher J White John Ochsner Heart and Vascular Institute Ochsner Medical Center 1514 Jefferson Highway New Orleans, LA 70121 USA Email: [email protected]
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
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Verma et al.
Figure 1. Magnetic resonance angiography showing a possible subclavian artery flow void or an artifact (arrow).
Figure 2. Retrograde subclavian angiography showing in-stent restenosis (arrow).
laboratory for left subclavian angiography prior to possible endovascular intervention for her symptoms of left arm claudication. In the catheterization laboratory, the left radial artery access site was prepped and draped; it was chosen for the site of arterial access to avoid catheter contact with the extensive aortic arch atheroma that would occur with femoral artery access. We also felt that there was a possibility of an occluded left subclavian stent, which would be easier to cross retrograde from radial artery access, although a potential disadvantage of the radial technique is that it may be more difficult to see the proximal edge of the stenosis by retrograde angiography. After local anesthesia, a 5 French sheath (Terumo Medical Corporation, Somerset, NJ, USA) was inserted into the left radial artery. Intravenous unfractionated heparin was employed as an anticoagulant during the procedure maintaining an activated clotting time of 250–300 seconds. A 5 French Judkins right diagnostic catheter was advanced over a 0.035 inch × 180 cm J-wire to the left subclavian artery and selective left subclavian angiography was performed demonstrating a moderately severe, 70% diameter narrowing within the previously placed subclavian stent (Figure 2). Using a 5 French Judkins right diagnostic catheter and a 0.035 inch × 180 cm stiff, angled Glidewire (Terumo Medical Corporation), the lesion was crossed and the stiff, angled Glidewire was positioned into the descending aorta. The 5 French Judkins right diagnostic catheter was then advanced over the stiff, angled Glidewire to the descending aorta. The stiff, angled Glidewire was removed and a pressure gradient of 30 mmHg across the proximal segment of the left subclavian artery stent was recorded. A 20 mmHg peak systolic or a 10 mmHg mean translesional pressure gradient is generally acceptable for intervention by expert consensus, not by evidence-based guidelines. The pressure gradient obtained during the catheterization was not simultaneous with the arm-to-arm blood pressure discrepancy. Also, the pressure gradient during the
catheterization was translesional between the proximal segment of subclavian artery and descending aorta. Next, a 0.035 inch × 260 cm Amplatz Extra-Stiff Wire Guide (Cook Medical, Bloomington, IN, USA) was inserted into the Judkins right diagnostic catheter and positioned in the descending aorta. The Judkins right diagnostic catheter and 5 French sheath were then removed and exchanged for a 55 cm long 6 French Raabe sheath (Cook Medical). The in-stent restenosis was predilated with a 6.0 mm × 40 mm balloon (Mustang; Boston Scientific Corporation, Natick, MA, USA) followed by an 8.0 mm × 40 mm balloon (Figure 3), resulting in a residual stenosis of about 10% (Figure 4). The translesional pressure gradient was zero following balloon dilation. With an excellent angiographic result (< 30% residual stenosis without a flow-limiting dissection) and resolution of the translesional gradient, the decision was made to not place a new stent within the original stent. The catheters were removed and local hemostasis was obtained. Following angioplasty the patient did well and was discharged home. Her claudication resolved and she has been doing well 6 months subsequent to her procedure.
Discussion Obstruction of the brachiocephalic or subclavian artery accounts for approximately 17% of symptomatic extracranial cerebrovascular disease1 and frequently is responsible for ipsilateral arm claudication or subclavian steal syndrome. In patients with internal mammary artery (IMA) coronary bypass grafts, left subclavian stenosis may cause symptoms of coronary ischemia.11 Brachiocephalic or subclavian artery revascularization is usually indicated for symptomatic patients and to protect inflow into internal mammary coronary graft, axillofemoral, axilloaxillary or subclavian-carotid graft. Restenosis, or reduction in lumen diameter after catheter-based percutaneous therapy of the
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
352
Vascular Medicine 18(6)
Figure 3. Percutaneous transluminal angioplasty with balloon inflation.
Figure 4. Angiography following balloon angioplasty demonstrating < 30% residual stenosis.
subclavian artery, is the result of arterial damage with subsequent neointimal tissue hyperplasia. Binary angiographic restenosis is defined as ≥ 50% luminal narrowing at followup angiography, although standardized classifications, as described in the coronary beds,12 are lacking in the brachiocephalic and subclavian arteries.
Balloon angioplasty of the subclavian and brachiocephalic arteries was first described in 1980 as an alternative to surgical revascularization.2 Percutaneous catheter-based treatment offers a less invasive approach and carries a lower rate of procedural complications compared to open surgery, including lower peri-procedural morbidity, fewer deaths, and a lower stroke rate accompanied by a shorter hospital stay.2,3 The choice of vascular access (i.e. radial, brachial, or femoral) is critical in determining equipment choices such as sheaths, guide catheters, guide wires, balloons, or stents. Radial artery access offers significant advantages such as lower access site bleeding complications, early ambulation, and same day discharge. Radial access is also preferred when extensive aortoilliac disease is present, as in our case. A larger-sized sheath can potentially lead to thrombosis and occlusion of the radial artery. This can be avoided by using smaller-sized sheaths, using guiding catheters without sheaths, anticoagulation during the procedure and nonocclusive hemostasis post procedure. For the purpose of intervention, either 6 French or 7 French sheaths (Flexor Shuttle, Flexor Ansel or Flexor Raabe; Cook Medical) or 8 French or 9 French guide catheters are used. From the radial or brachial approach, both sheath and guide may be equally beneficial. We planned for balloon only, but were prepared to place another stent if there was recoil or an edge dissection. Even though the risk of radial artery occlusion is increased with a larger sheath size, we thought it was prudent to plan ahead for contingencies and easier to begin with an appropriate-sized sheath than to have to change in the middle of the procedure. For subclavian ostial lesions, a guide catheter offers more control and steerability compared to a long sheath (80–100 cm) from the femoral access. From the brachial artery access, a 55 cm sheath may be used. A brachial or radial approach may limit visualization of the proximal edge of the stenosis by retrograde angiography. Using a diagnostic catheter such as a 4 French Multipurpose or a Judkins right catheter, the lesion may be crossed with a steerable 0.035 inch guide wire (Wholey Guidewire; Covidien, Mansfield, MA, USA) or it may be necessary to use a hydrophilic guide wire such as a 0.035 inch Glidewire (Terumo Medical Corporation). This steerable wire can then be exchanged for a more supportive and stiffer 0.035 inch guide wire such as the Amplatz Extra-Stiff Wire Guide (Cook Medical) intended to facilitate the placement and exchange of interventional devices such as the PTA balloon and stent during an interventional procedure. It is important to avoid disrupting the origin of the internal mammary artery. This goal is best achieved by delineating the origin of the vessel by performing the angiogram in the contralateral oblique projection. A 0.014 inch guide wire may also be placed in the internal mammary artery to protect the access to the vessel. While the reported rates of restenosis at 3 years are as high as 21% with PTA alone,13 primary stenting for symptomatic subclavian and brachiocephalic artery lesions, including occlusions, has been described to be successfully accomplished in 98% of patients with 83% primary and 96% secondary patency rates at an average of more than 5 years of follow up.5 For in-stent restenosis, balloon angioplasty using an appropriately sized balloon may be adequate to treat the
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
353
Verma et al. obstruction. Although stents offer superior long-term patency over PTA for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Alternative treatment options for in-stent restenosis would include: (1) restenting; (2) covered stents; and (3) brachytherapy. There is no evidence to support an advantage for any of these options, but the placement of a covered stent is technically challenging and more difficult that the most simple solution, PTA. We prefer to escalate risk, starting with the simplest solution and progressing to more difficult if there is a second in-stent restenosis. The method of failure for covered stents is acute thrombosis rather than gradual restenosis, which is less attractive. Brachytherapy is not commercially available. When drug-coated balloons become available in the US market, they will be an attractive option. Again, using embolic protection complicates this procedure and must be weighed against the theoretical risk that this very rare complication might occur. There is no evidence that a cutting balloon has any utility for in-stent restenosis, but it has only been systematically studied in coronaries. The cutting balloon does cost significantly more than a conventional balloon, so it is hard to use without some supportive evidence. With an excellent angiographic result and the gradient abolished, we treated in-stent restenosis with just balloon angioplasty alone. In conclusion, provisional stenting with angioplasty alone when the PTA results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis. Declaration of conflicting interest The authors declare no conflicts.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Fields WS, Lemak NA. Joint study of extracranial arterial occlusion. VII. Subclavian steal–a review of 168 cases. JAMA 1972; 222: 1139–1143.
2. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999; 33: 1238–1245. 3. Eisenhauer AC. Subclavian and innominate revascularization: Surgical therapy versus catheter-based intervention. Curr Interv Cardiol Rep 2000; 2: 101–110. 4. De Vries JP, Jager LC, Van den Berg JC, et al. Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg 2005; 41: 19–23. 5. Patel SN, White CJ, Collins TJ, et al. Catheter-based treatment of the subclavian and innominate arteries. Catheter Cardiovasc Interv 2008; 71: 963–968. 6. Tepe G, Zeller T, Albrecht T, et al. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl J Med 2008; 358: 689–699. 7. Laird JR, Zeller T, Gray BH, et al. Limb salvage following laser-assisted angioplasty for critical limb ischemia: results of the LACI multicenter trial. J Endovasc Ther 2006; 13: 1–11. 8. Saxon RR, Coffman JM, Gooding JM, Ponec DJ. Long-term patency and clinical outcome of the Viabahn stent-graft for femoropopliteal artery obstructions. J Vasc Interv Radiol 2007; 18: 1341–1349; quiz 1350. 9. Dake MD, Ansel GM, Jaff MR, et al. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Circ Cardiovasc Interv 2011; 4: 495–504. 10. Werner M, Scheinert D, Henn M, et al. Endovascular brachytherapy using liquid Beta-emitting rhenium-188 for the treatment of long-segment femoropopliteal in-stent stenosis. J Endovasc Ther 2012; 19: 467–475. 11. Tsyvine D, Hartzell M, Bonaca MP, Connors G, Kinlay S. Subclavian stenosis causing angina after coronary artery bypass grafting. Med J Aust 2009; 190: 331–332. 12. Mehran R, Dangas G, Abizaid AS, et al. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation 1999; 100: 1872–1878. 13. Angle JF, Matsumoto AH, McGraw JK, et al. Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up. Vasc Endovasc Surg 2003; 37: 89–97.
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
Management of subclavian artery in-stent restenosis Anil Verma, John P Reilly and Christopher J White Vasc Med 2013 18: 350 originally published online 30 October 2013 DOI: 10.1177/1358863X13509129 The online version of this article can be found at: http://vmj.sagepub.com/content/18/6/350
Published by: http://www.sagepublications.com
On behalf of:
Society for Vascular Medicine
Additional services and information for Vascular Medicine can be found at: Email Alerts: http://vmj.sagepub.com/cgi/alerts Subscriptions: http://vmj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 29, 2013 OnlineFirst Version of Record - Oct 30, 2013 What is This?
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
09129
VMJ18610.1177/1358863X13509129Vascular MedicineVerma et al.
Case Report
Management of subclavian artery in-stent restenosis
Vascular Medicine 18(6) 350–353 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1358863X13509129 vmj.sagepub.com
Anil Verma, John P Reilly and Christopher J White
Abstract Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause a significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart. An endovascular approach with primary stenting or provisional stenting has become the primary modality of revascularization of subclavian artery stenosis. In-stent restenosis can be treated with percutaneous transluminal angioplasty or repeat stenting and although stents offer superior long-term patency over balloon angioplasty alone for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Here we describe a case of subclavian in-stent restenosis treated with just balloon angioplasty and demonstrate that provisional stenting with angioplasty alone when the percutaneous transluminal angioplasty results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis. Keywords peripheral vascular diseases; restenosis; stenosis; stents; subclavian artery
Background Stenotic and occlusive diseases of the subclavian and brachiocephalic arteries can cause significant morbidity as it can lead to symptomatic ischemia affecting the upper extremities, brain and, in some cases, the heart.1 Primary stenting or provisional stenting (i.e. stenting after failed or suboptimal balloon angioplasty) has become the primary modality of revascularization for subclavian and brachiocephalic arteries because of a high clinical success rate and a lower rate of procedural complications as compared to open surgery.2,3 Endovascular revascularization of atherosclerotic subclavian stenosis with stenting is associated with a technical success rate of 92% to 100% with 2–5-year patency rates ranging from 77% to 89%,4,5 comparable to surgery. Stenting is preferred over percutaneous transluminal angioplasty (PTA) alone because of the uncertain longterm patency and high failure rate of PTA when treating occlusions. In-stent restenosis can be treated with PTA or repeat stenting but there is a paucity of comparative data regarding how best to treat subclavian artery in-stent restenosis. Paclitaxel-coated balloon angioplasty,6 excimer laser debulking,7 stent grafting,8 drug-coated stents9 and brachytherapy10 have been used in the treatment of femoropopliteal in-stent restenosis with variable results, but the role of each of these technologies in the treatment of subclavian artery in-stent restenosis is unknown.
Case report The patient is a 59-year-old woman who presented to our clinic with symptoms of left arm claudication with minimal
arm activity. She was treated with bilateral subclavian artery stents about 10 years previously. She has a history of hypertension, hyperlipidemia and coronary artery disease with coronary artery bypass surgery using a left internal mammary arterial conduit to the left anterior descending artery. She currently denies angina pectoris. She continues to smoke and has a history of peripheral arterial disease with common iliac artery stenosis treated with bilateral stents. She has a past history of ischemic stroke with extensive aortic arch atheroma identified on transesophageal echocardiography. On physical examination, systolic blood pressure was 50 mmHg greater in the right arm compared to the left arm. Magnetic resonance angiography (MRA), performed to investigate symptoms of stroke, demonstrated a possible near occlusion of the left subclavian artery ostium or an artifact (Figure 1). The utility of the MRA may be limited due to the void artifact caused by the metal stent. The MRA report was unreliable due to the metal artifact and thus the patient was taken to the catheterization Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA, USA Dr Scott Kinlay was the guest editor for this article. Corresponding author: Christopher J White John Ochsner Heart and Vascular Institute Ochsner Medical Center 1514 Jefferson Highway New Orleans, LA 70121 USA Email: [email protected]
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
351
Verma et al.
Figure 1. Magnetic resonance angiography showing a possible subclavian artery flow void or an artifact (arrow).
Figure 2. Retrograde subclavian angiography showing in-stent restenosis (arrow).
laboratory for left subclavian angiography prior to possible endovascular intervention for her symptoms of left arm claudication. In the catheterization laboratory, the left radial artery access site was prepped and draped; it was chosen for the site of arterial access to avoid catheter contact with the extensive aortic arch atheroma that would occur with femoral artery access. We also felt that there was a possibility of an occluded left subclavian stent, which would be easier to cross retrograde from radial artery access, although a potential disadvantage of the radial technique is that it may be more difficult to see the proximal edge of the stenosis by retrograde angiography. After local anesthesia, a 5 French sheath (Terumo Medical Corporation, Somerset, NJ, USA) was inserted into the left radial artery. Intravenous unfractionated heparin was employed as an anticoagulant during the procedure maintaining an activated clotting time of 250–300 seconds. A 5 French Judkins right diagnostic catheter was advanced over a 0.035 inch × 180 cm J-wire to the left subclavian artery and selective left subclavian angiography was performed demonstrating a moderately severe, 70% diameter narrowing within the previously placed subclavian stent (Figure 2). Using a 5 French Judkins right diagnostic catheter and a 0.035 inch × 180 cm stiff, angled Glidewire (Terumo Medical Corporation), the lesion was crossed and the stiff, angled Glidewire was positioned into the descending aorta. The 5 French Judkins right diagnostic catheter was then advanced over the stiff, angled Glidewire to the descending aorta. The stiff, angled Glidewire was removed and a pressure gradient of 30 mmHg across the proximal segment of the left subclavian artery stent was recorded. A 20 mmHg peak systolic or a 10 mmHg mean translesional pressure gradient is generally acceptable for intervention by expert consensus, not by evidence-based guidelines. The pressure gradient obtained during the catheterization was not simultaneous with the arm-to-arm blood pressure discrepancy. Also, the pressure gradient during the
catheterization was translesional between the proximal segment of subclavian artery and descending aorta. Next, a 0.035 inch × 260 cm Amplatz Extra-Stiff Wire Guide (Cook Medical, Bloomington, IN, USA) was inserted into the Judkins right diagnostic catheter and positioned in the descending aorta. The Judkins right diagnostic catheter and 5 French sheath were then removed and exchanged for a 55 cm long 6 French Raabe sheath (Cook Medical). The in-stent restenosis was predilated with a 6.0 mm × 40 mm balloon (Mustang; Boston Scientific Corporation, Natick, MA, USA) followed by an 8.0 mm × 40 mm balloon (Figure 3), resulting in a residual stenosis of about 10% (Figure 4). The translesional pressure gradient was zero following balloon dilation. With an excellent angiographic result (< 30% residual stenosis without a flow-limiting dissection) and resolution of the translesional gradient, the decision was made to not place a new stent within the original stent. The catheters were removed and local hemostasis was obtained. Following angioplasty the patient did well and was discharged home. Her claudication resolved and she has been doing well 6 months subsequent to her procedure.
Discussion Obstruction of the brachiocephalic or subclavian artery accounts for approximately 17% of symptomatic extracranial cerebrovascular disease1 and frequently is responsible for ipsilateral arm claudication or subclavian steal syndrome. In patients with internal mammary artery (IMA) coronary bypass grafts, left subclavian stenosis may cause symptoms of coronary ischemia.11 Brachiocephalic or subclavian artery revascularization is usually indicated for symptomatic patients and to protect inflow into internal mammary coronary graft, axillofemoral, axilloaxillary or subclavian-carotid graft. Restenosis, or reduction in lumen diameter after catheter-based percutaneous therapy of the
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
352
Vascular Medicine 18(6)
Figure 3. Percutaneous transluminal angioplasty with balloon inflation.
Figure 4. Angiography following balloon angioplasty demonstrating < 30% residual stenosis.
subclavian artery, is the result of arterial damage with subsequent neointimal tissue hyperplasia. Binary angiographic restenosis is defined as ≥ 50% luminal narrowing at followup angiography, although standardized classifications, as described in the coronary beds,12 are lacking in the brachiocephalic and subclavian arteries.
Balloon angioplasty of the subclavian and brachiocephalic arteries was first described in 1980 as an alternative to surgical revascularization.2 Percutaneous catheter-based treatment offers a less invasive approach and carries a lower rate of procedural complications compared to open surgery, including lower peri-procedural morbidity, fewer deaths, and a lower stroke rate accompanied by a shorter hospital stay.2,3 The choice of vascular access (i.e. radial, brachial, or femoral) is critical in determining equipment choices such as sheaths, guide catheters, guide wires, balloons, or stents. Radial artery access offers significant advantages such as lower access site bleeding complications, early ambulation, and same day discharge. Radial access is also preferred when extensive aortoilliac disease is present, as in our case. A larger-sized sheath can potentially lead to thrombosis and occlusion of the radial artery. This can be avoided by using smaller-sized sheaths, using guiding catheters without sheaths, anticoagulation during the procedure and nonocclusive hemostasis post procedure. For the purpose of intervention, either 6 French or 7 French sheaths (Flexor Shuttle, Flexor Ansel or Flexor Raabe; Cook Medical) or 8 French or 9 French guide catheters are used. From the radial or brachial approach, both sheath and guide may be equally beneficial. We planned for balloon only, but were prepared to place another stent if there was recoil or an edge dissection. Even though the risk of radial artery occlusion is increased with a larger sheath size, we thought it was prudent to plan ahead for contingencies and easier to begin with an appropriate-sized sheath than to have to change in the middle of the procedure. For subclavian ostial lesions, a guide catheter offers more control and steerability compared to a long sheath (80–100 cm) from the femoral access. From the brachial artery access, a 55 cm sheath may be used. A brachial or radial approach may limit visualization of the proximal edge of the stenosis by retrograde angiography. Using a diagnostic catheter such as a 4 French Multipurpose or a Judkins right catheter, the lesion may be crossed with a steerable 0.035 inch guide wire (Wholey Guidewire; Covidien, Mansfield, MA, USA) or it may be necessary to use a hydrophilic guide wire such as a 0.035 inch Glidewire (Terumo Medical Corporation). This steerable wire can then be exchanged for a more supportive and stiffer 0.035 inch guide wire such as the Amplatz Extra-Stiff Wire Guide (Cook Medical) intended to facilitate the placement and exchange of interventional devices such as the PTA balloon and stent during an interventional procedure. It is important to avoid disrupting the origin of the internal mammary artery. This goal is best achieved by delineating the origin of the vessel by performing the angiogram in the contralateral oblique projection. A 0.014 inch guide wire may also be placed in the internal mammary artery to protect the access to the vessel. While the reported rates of restenosis at 3 years are as high as 21% with PTA alone,13 primary stenting for symptomatic subclavian and brachiocephalic artery lesions, including occlusions, has been described to be successfully accomplished in 98% of patients with 83% primary and 96% secondary patency rates at an average of more than 5 years of follow up.5 For in-stent restenosis, balloon angioplasty using an appropriately sized balloon may be adequate to treat the
Downloaded from vmj.sagepub.com at Scientific library of Moscow State University on February 4, 2014
353
Verma et al. obstruction. Although stents offer superior long-term patency over PTA for de novo lesions, there are no data regarding primary versus provisional stenting in subclavian in-stent restenosis. Alternative treatment options for in-stent restenosis would include: (1) restenting; (2) covered stents; and (3) brachytherapy. There is no evidence to support an advantage for any of these options, but the placement of a covered stent is technically challenging and more difficult that the most simple solution, PTA. We prefer to escalate risk, starting with the simplest solution and progressing to more difficult if there is a second in-stent restenosis. The method of failure for covered stents is acute thrombosis rather than gradual restenosis, which is less attractive. Brachytherapy is not commercially available. When drug-coated balloons become available in the US market, they will be an attractive option. Again, using embolic protection complicates this procedure and must be weighed against the theoretical risk that this very rare complication might occur. There is no evidence that a cutting balloon has any utility for in-stent restenosis, but it has only been systematically studied in coronaries. The cutting balloon does cost significantly more than a conventional balloon, so it is hard to use without some supportive evidence. With an excellent angiographic result and the gradient abolished, we treated in-stent restenosis with just balloon angioplasty alone. In conclusion, provisional stenting with angioplasty alone when the PTA results are excellent is a reasonable alternative to primary stent placement for subclavian in-stent restenosis. Declaration of conflicting interest The authors declare no conflicts.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Fields WS, Lemak NA. Joint study of extracranial arterial occlusion. VII. Subclavian steal–a review of 168 cases. JAMA 1972; 222: 1139–1143.
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