Correspondence Address: Dr. Santhosh Krishnappa Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, TB Sanitorium Campus, K.R.S. Road, Mysore, Karnataka India
Source of Support: None, Conflict of Interest: None
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.
How to cite this article: Krishnappa S, Rachaiah JM, Hegde SS, Sadananda KS, Nanjappa MC, Ramasanjeevaiah G. Percutaneous antegrade and retrograde endovascular approach to symptomatic high-grade subclavian artery stenosis: Technique and follow-up. Heart Views 2019;20:87-92
How to cite this URL: Krishnappa S, Rachaiah JM, Hegde SS, Sadananda KS, Nanjappa MC, Ramasanjeevaiah G. Percutaneous antegrade and retrograde endovascular approach to symptomatic high-grade subclavian artery stenosis: Technique and follow-up. Heart Views [serial online] 2019 [cited 2022 May 20];20:87-92. Available from: https://www.heartviews.org/text.asp?2019/20/3/87/267842
Angioplasty and stent placement in symptomatic subclavian artery stenosis have evolved as effective and safe treatment techniques since the 1990s.,,, Standard open surgical procedures are now mostly reserved for extensive multivessel involvement or after failed endovascular procedures. Indications for treatment include clinical symptoms ranging from upper limb ischemia and subclavian steal syndrome to vertebra basilar insufficiency.,
Treatment options include endovascular treatment, including balloon angioplasty and/or stent placement, surgery, or combination of both. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure are used.
Endovascular stent-placement interventions have been reported with high technical and clinical success rates, low complication rates, and good midterm patency rates.,, However, potential embolic complications during balloon inflation and stent deployment to vertebral artery as well as restenosis remain an important concern. The purpose of this study was to determine the safety, efficacy, and midterm clinical and radiologic outcome of the endovascular treatment, with special focus on the different technical approaches.
Materials and Methods
We at our center performed subclavian artery angioplasty for 11 patients (10 men, 1 woman) between 2014 and 2017 aged 51.3 years (range, 32–61 years) with high-grade (90%–100%) symptomatic stenosis. Patients were selected for endovascular therapy after discussion with patient and their relatives, after informed consent. All interventions were part of routine clinical management. Patient data, technical and clinical success, complications of the procedure, and results of follow-up controls were reviewed retrospectively from the patients' charts and radiologic reports. The patients' characteristics, clinical symptoms, cardiovascular risk factors, and comorbidities are summarized in [Table 1].
Table 1: Patient, lesion, and procedure characteristics
All patients underwent preinterventional clinical examination with bilateral arm pressure measurements and duplex sonography. As part of the preoperative workup, patients underwent either computerized tomography angiogram (CTA) or conventional angiogram to confirm the suspected lesion.
Percutaneous transarterial angioplasty with or without stent placement was performed with the patient under local anesthesia, in the angiography suite on a high-resolution angiography system (Philips, FD 10). Access to the lesion was gained through a percutaneous puncture of the right common femoral artery alone in three patients and using ipsilateral brachial and right common femoral artery accesses in eight patients.
Technical characteristics of the interventions are summarized in [Table 1]. Using antegrade femoral [Figure 1] and [Figure 2] or retrograde brachial approach [Figure 3], we obtained angiographic images using either a 6F multipurpose or 6F Judkins right diagnostic catheter to define the exact location and severity of the lesion; then, a 7F multipurpose or 7F Judkins right guiding catheter was used to do angioplasty.
Figure 1: Antegrade only approach (a): Left subclavian artery lesion, (b): Stent deployment, (c): Final Result, (d): Left subclavian artery lesion in takayasu arteritis, (e): Balloon dilatation, (f): Final result
Figure 2: Percutaneous transluminal angioplasty of a tortous right subclavian artery chronic total occlusion (a):Occlusion of right subclavian artery, (b): balloon dilatation, (c): Stent deployment, (d): Final result
Figure 3: Retrograde crossing the lesion, followed by snaring from femoral artery making arterio-arterial loop and stenting from antegrade approach (a): Left suclavian artery occlusion, (b): Snaring from right femoral artery and formation of the arterio-arterial loop, (c): Antegrade catheter tracking with the help of retrograde catheter, (d): Stent deployment, (e): Ostial flaring of the stent, (f): Final result
For the brachial approach [Figure 3] and Video 1], a 6F multipurpose diagnostic catheter was used. Guidewires measuring 0.028–0.035 inch were used, depending on the availability in the catheterization laboratory. In all cases, the procedure was completed via the femoral approach because of better visualization, stable stent position, and easier stent deployment. In patients with a combined brachial and femoral approach [Figure 3], through the transbrachial approach, a 0.028–0.032 inch (260 cm long) guidewire (Radio focus Guide Wire; Terumo, Tokyo, Japan) was navigated retrogradely into the descending aorta. Then, using a snare [Figure 3]b and [Video 2], the wire was led through the femoral sheath resulting in a wire through the whole body from the brachial to the femoral artery [Videos 2 and 3]. This procedure allows the introduction of a smaller sheath for brachial access. The procedure was completed by antegrade stent placement from the femoral access [Videos 4 and 5].
All patients had left subclavian artery lesions except one, who had occlusion of anomalous right subclavian artery which was arising from descending thoracic aorta distal to the origin of left subclavian artery, suggestive of arteria lusoria. Angioplasty and stenting were done from femoral only access in this patient successfully [Figure 2].
Stent selection was based on vessel reference diameter and lesion length. Stainless balloon-expandable stents were preferred due to their better delivery profile and deployment precision, except two. In one patient, self-expandable nitinol stent was deployed due to nonavailability of balloon expandable stent. In another case, stent was not used as it was a case of Takayasu arteritis. The stent diameter was chosen not to exceed the vessel reference diameter. We used stent with diameter which varied from 7 to 8 mm (mean of 7.9 mm) and the length from 29 to 59 mm (mean of 42.3 mm).
After the interventional procedure, a final angiography was always performed to confirm the technical success and patency of the vessel [Video 6]. Technical success was defined as a stenosis grade reduction of >80% of the target vessel. No embolic protection device was used.
All patients were given aspirin 325 mg and clopidogrel 300 mg as a loading dose 6–12 h before the procedure and continued with aspirin 150 mg once a day and clopidogrel 75 mg once a day for 1 year followed by single antiplatelet. During the procedure, 5000–8000 IU of heparin was administered.
Clinical follow-up consisted of a history of recurrent or new onset of symptoms, physical examination including peripheral pulses, bilateral arm blood pressure measurement, and duplex sonography postinterventionally and at 1, 3, and 12 months and 6 monthly thereafter. CTA or conventional angiogram was done if significant change in the duplex examination or relevant clinical symptoms occurred and if duplex sonography was not conclusive or if additional new or progressive occlusive lesions were suspected.
Stent deployment could be achieved in 10 out of 11 patients. One patient did not undergo stent implantation as the basic diagnosis was nonatherosclerotic (Takayasu arteritis) [Figure 1]d, [Figure 1]e,[Figure 1]f.
Technical success rate was 100% (10/11).
One patient had subintimal tracking into descending thoracic aorta of the Terumo guide wire with diagnostic catheter [Figure 4]. Later, it re-entered the true lumen. Patient was followed up clinically. He was comfortable. There was no procedure-related permanent morbidity or mortality. No access-related complication occurred.
Figure 4: Subintimal tracking into descending thoracic aorta while attempting a retrograde approach
Follow-up varied between 5 and 44 months (mean of 22.5 months). At least one clinical and radiologic follow-up could be performed in all 11 patients. Immediate complete resolution or improvement of the symptoms could be achieved in all patients. Normalization of blood pressure was achieved in all the patients.
At the latest clinical follow-up, all patients showed an excellent or good clinical outcome. Two patients (18.2%) needed repeat procedure due to a symptomatic restenosis of the lesion. Both underwent balloon angioplasty without stent implantation with excellent results [Figure 5]. In all other patients, no significant restenosis was found at the latest follow-up.
Figure 5: Angioplasty of a restenosed subclavian artery lesion (a): Crossing restenosis, (b): Snaring and formation of arterio-arterial loop, (c): Crossing lesion with the catheter, (d): Exchanging with stiffer wire to get additional support, (e): Balloon dilatation, (f): Final result
Symptomatic stenosis of the subclavian artery is not an uncommon disease, predominant etiology being atherosclerotic. Takayasu arteritis stands second only to atherosclerosis to involve the subclavian artery. Subclavian artery disease will be highly fibrotic. Different approaches and methods have been described, ranging from minimally invasive percutaneous endovascular angioplasty and stent placement to open, hybrid, and combined approaches. Percutaneous approach to subclavian arterial stenosis is often used with stenting as first line therapy in symptomatic patients.,
Occlusive subclavian disease will be fibrotic. If it is long-standing, it may face difficulties crossing the lesion. Combined antegrade and retrograde approach like ours making an arterio-arterial loop will give sufficient support and increase the success of the procedure.
A controlled antegrade and retrograde subintimal tracking (CART) is a technique developed to facilitate the recanalization of chronic total occlusion (CTOs) by aggressive wire manipulation from both ends of the lesions., In the classic CART, a balloon (1.25–2.5 mm) is positioned in the CTO and inflated over the retrograde wire into the retrograde subintimal space, parallel to the antegrade wire. The antegrade wire is manipulated to connect with the enlarged retrograde subintimal space to ultimately exit into the distal true lumen. A bilateral approach for CTO lesions using the CART technique is feasible, safe and had higher success rate.
There is no conclusive evidence to determine whether stenting is more effective than plain balloon angioplasty.,, However, in a systematic review (544 patients) comparing both options, stenting was superior to angioplasty alone, with a higher patency rate at 1 year indicated by the absence of events.
Technical success of endovascular therapy is 100% when treating stenosis and 80%–95% when treating occlusions. In heavily calcified ostial lesions, in addition to an easier placement, balloon expandable stents give more radial force than nitinol stents. Midterm patency (≥24 months) following subclavian endovascular therapy is 70%–85%. Nowadays, endovascular approach is often the default strategy. However, in selected patients with low operative risk, with subclavian artery occlusion or after endovascular therapy failure, surgical subclavian–carotid transposition is safe with good long-term patency results (5-year patency 96%).,
Carotid–subclavian bypass surgery with a prosthetic graft showed long-term benefit with low operative mortality and morbidity rates, especially in patients with extensive disease or reocclusion after stenting (5-year patency, 97%).
Other options are extra thoracic extra-anatomic bypass procedures (axillo-axillary, carotid–axillary, or carotid–carotid bypass)., A transthoracic approach is an option in patients with multivessel disease involving the aortic arch and several supra-aortic vessels.
In symptomatic patients with contraindications for endovascular therapy or open surgery, prostanoid infusion or thoracic sympathectomy may be considered. Antegrade (femoral), retrograde (brachial or radial), or combined should be preferred depending on the lesion location and severity., They have their own advantages and disadvantages.
Femoral artery approach should be chosen in subtotal lesions, lesions with sufficient stump at the proximal subclavian artery. Brachial or radial should be preferred in ostial total occlusion where there is no stump, long-segment lesion, tortuous subclavian or abnormal take off from aortic arch. Stent implantation requires a larger sheath (minimum of 7F) and a larger guide catheter (minimum of 8F); hence, it is better to deploy stent from femoral approach after snaring the wire which is passed from brachial or radial access as we did in our cases. Not only the size of the sheath and catheter mandates femoral completion but also precise placement of a short stent requires a stable situation, which can be obtained with a wire from the femoral to the brachial sheath, which can be stretched during deployment of the stent. Hence, it is always better to complete the procedure from femoral access.
Percutaneous endovascular therapy is the preferred mode of therapy in subclavian artery disease. Antegrade or combined antegrade and retrograde approach improves procedural success rate and clinical outcome. Additional retrograde approach should be used judiciously, safely whenever indicated.
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