Angioplasty and Stenting of the Great VesselsJ. Bayne Selby, Jr., MDMedical University of South CarolinaInstitut fur Diagnostische und Interventionelle RadiologieUniversitat Frankfurt am MainJune 7, 2006

History1964 First angioplasty report by Dotter and Judkins1980 First subclavian angioplasty report by Bachman and Kim1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary bypass graft1993 First subclavian stent use reported by Mathias

OverviewStenoses/occlusion in the great vessels usually represent difficult areas to access surgicallyResults with angioplasty have been uniformly good in stenosesUse of stents has resulted in similar results for complete occlusionsRole of distal embolic protection devices unclear at this time

95% Left Subclavian StenosisPrePostPost Aortagram

Left Subclavian Stenosis Pre, Post, and 6 month follow-upPreImmediate Post6 months post

Patient SelectionAs always, treatment should only be performed in those patients who have both a hemodynamically significant lesion and appropriate corresponding symptoms

Anatomic LocationsLeft Subclavian (most common)BrachiocephalicLeft Common Carotid OriginRight Subclavian (often in aberrant vessel)

IndicationsUpper Extremity IschemiaArm ClaudicationEmboli from lesion to handCerebral IschemiaAnterior (carotid) symptomsVertebro-basilar Insufficiency w/wo subclavian stealDiminished Inflow to GraftAngina in patient with LIMAClaudication in patient with Ax-fem

DiagnosisClinical HistoryBLOOD PRESSURES in both arms simpleMRACTAConventional Angiography AP and LAO

Diagnostic AngiographyEvaluate for central lesion (stenosis/occlusion)Evaluate for evidence of distal emboli (then do echocardiography of heart)Evaluate for vasospastic disorder, e.g., Raynauds (do angio before and after vasodilator)Evaluate for thoracic outlet syndrome (do abduction and adduction angio)

Great Vessel Angioplasty/Stent Technique

Do baseline neurological examInitial high quality diagnostic thoracic aortagramArteriography of distal vascular beds as allowed by degree of diseaseFirst attempt to cross lesion from belowUse brachial approach if necessaryGive Heparin once lesion has been crossed (2,000-3,000 units)

Great Vessel Angioplasty/Stent TechniqueHave nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, smile, wiggle toes)Use guiding catheter or sheathTry to use appropriate ballon size for initial dilatation, but pre-dilate if lesion is too tight to get acrossLeave balloon up for 10 secondsStent for >30% residual stenosis, dissection, recoilConsider primary stent based on appearance of lesion

Brachiocephalic (Innominate) Artery Angioplasty99% stenosis at originof brachiocephalic arteryCross lesion from an axillary approach

Brachiocephalic (Innominate) Artery Angioplasty10 mm balloon with waist10 mm balloon fully inflated

Brachiocephalic (Innominate) Artery AngioplastyInitial 99% stenosisFinal with residual stenosis

Subclavian Stenosis proximal to LIMA coronary graft no stentDiffuse stenosis poor fillingof the LIMA graftS/P Angioplasty circa 1991

Stenosis in Single supra-aortic Vessel Now What?

Follow up MR? CT? Angio?Peloschek P., et al. The Role of Multi-slice Spiral CT Angiography in Patient Management After Endovascular Therapy. Cardiovascular and Interventional Radiology, In Press

Subclavian Stenosis proximal to LIMA coronary graft with stent

Stenosis within stent

Bifurcation LesionsCan occur at right subclavian right common carotid bifurcationMust use RAO projection to evaluate stenosisOptions include: 1) simple angioplasty2) kissing balloon angioplasty3) simple stent4) kissing stents

Bifurcation LesionsSubclavian Steal95% stenosis in proximalright subclavian artery

Bifurcation LesionsKissing balloon from femoral andright axillary approachFinal ResultExcellent is the Enemy of Good!

Bifurcation LesionPulse Volume RecordingsRight ArmLeft ArmFingers of Right Hand

Life Table Analysis30 Subclavian Angioplasty Patients University of Virginia

Summary of Largest Series of PTA of Brachiocephalic Arterial Stenoses

Summary of Series of Brachiocephalic Arterial Occlusions

ComplicationsPuncture site complications, femoral or brachialRupture of vesselEmboli from angioplasty siteStent misplacement

ComplicationsMathias, et al: 38 patients with total occlusions No significant embolic occlusions

ComplicationsLiterature review by Kachel, et al: 774 supraaortic lesions treated with PTA0.5% Major complications3.5% Minor complications

Explanations20 second delay in restoration of antegrade flow in vertebral artery following angioplasty Ringelstein, et al, Nuclear Medicine dataLack of clinical significance of small emboli to handPossible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience)

Still, now we have protection devices Landing zone for protection device in supra-aortic angioplasty is often vessel too largeProbably should use it when possible

Were not done yet!Articles to be published in 20066 articles on results of simple angioplasty and/or stenting of great vessels3 articles on great vessel disease treatment in conjunction with thoracic aortic stent graft2 articles on percutaneous treatment for arteritis

ConclusionAngioplasty, with or without stenting is highly effective for stenoses of the great vesselsOcclusive disease in the great vessels should always be treated with stentLong term result are excellent (70-90%), but follow up with CTA upon return of symptoms may be necessaryConsider the use of distal embolic protection, although rate of complications has been low without it

SummaryAngioplasty of the Great Vessels can be a useful treatment in a surgically difficult areaResults mimic those of the common iliac arteries (>90% success) and have further improved with the use of stents, particularly for occlusionsImprovements in technology have increased the technical success in occlusionsComplications are low, but remain a hazard consideration should be given to the use of distal protection devices when anatomy is suitable