Angioplasty and StentingAngioplasty and Stenting

HistoryHistory

1964 First angioplasty report by Dotter 1964 First angioplasty report by Dotter and Judkinsand Judkins

1980 First subclavian angioplasty report 1980 First subclavian angioplasty report by Bachman and Kimby Bachman and Kim

1991 Report by Soulen for subclavian 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary angioplasty proximal to LIMA coronary bypass graftbypass graft

1993 First subclavian stent use reported 1993 First subclavian stent use reported by Mathiasby Mathias

OverviewOverview

Stenoses/occlusion in the great Stenoses/occlusion in the great vessels usually represent difficult vessels usually represent difficult areas to access surgicallyareas to access surgically

Results with angioplasty have been Results with angioplasty have been uniformly good in stenosesuniformly good in stenoses

Use of stents has resulted in similar Use of stents has resulted in similar results for complete occlusionsresults for complete occlusions

95% Left Subclavian 95% Left Subclavian StenosisStenosis

Pre Post Post Aortagram

Left Subclavian Stenosis – Pre, Left Subclavian Stenosis – Pre, Post, and 6 month follow-upPost, and 6 month follow-up

Pre Immediate Post 6 months post

Great Vessel Angioplasty/Stent Great Vessel Angioplasty/Stent TechniqueTechnique

Do baseline neurological examDo baseline neurological exam Initial high quality diagnostic thoracic Initial high quality diagnostic thoracic

aortagramaortagram Arteriography of distal vascular beds as Arteriography of distal vascular beds as

allowed by degree of diseaseallowed by degree of disease First attempt to cross lesion from belowFirst attempt to cross lesion from below Use brachial approach if necessaryUse brachial approach if necessary Give Heparin once lesion has been crossed Give Heparin once lesion has been crossed

(2,000-3,000 units)(2,000-3,000 units)

Great Vessel Angioplasty/Stent Great Vessel Angioplasty/Stent TechniqueTechnique

Have nurse perform neurological tests on patients Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, at regular intervals (e.g., speak, grip strength, smile, wiggle toes)smile, wiggle toes)

Use guiding catheter or sheathUse guiding catheter or sheath Try to use appropriate ballon size for initial Try to use appropriate ballon size for initial

dilatation, but pre-dilate if lesion is too tight to get dilatation, but pre-dilate if lesion is too tight to get acrossacross

Leave balloon up for 10 secondsLeave balloon up for 10 seconds Stent for >30% residual stenosis, dissection, recoilStent for >30% residual stenosis, dissection, recoil Consider primary stent based on appearance of Consider primary stent based on appearance of

lesionlesion

Subclavian Stenosis proximal Subclavian Stenosis proximal to LIMA coronary graft – with to LIMA coronary graft – with

stentstent

Stenosis within stentStenosis within stent

ConclusionConclusion

Angioplasty, with or without stenting is Angioplasty, with or without stenting is highly effective for stenoses of the great highly effective for stenoses of the great vesselsvessels

Occlusive disease in the great vessels Occlusive disease in the great vessels should always be treated with stentshould always be treated with stent

Long term result are excellent (70-90%), Long term result are excellent (70-90%), but follow –up with CTA upon return of but follow –up with CTA upon return of symptoms may be necessarysymptoms may be necessary

ReferencesReferences

Medical University of South CarolinaMedical University of South Carolina Web MDWeb MD Google BooksGoogle Books