Angioplasty and Stenting of the Great Vessels

Angioplasty and Stenting of Angioplasty and Stenting of the Great Vesselsthe Great Vessels

J. Bayne Selby, Jr., MDJ. Bayne Selby, Jr., MD

Medical University of South Medical University of South CarolinaCarolina

Institut fur Diagnostische und Interventionelle RadiologieUniversitat Frankfurt am Main

June 7, 2006

HistoryHistory

1964 First angioplasty report by Dotter and 1964 First angioplasty report by Dotter and JudkinsJudkins

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

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

1993 First subclavian stent use reported by 1993 First subclavian stent use reported by MathiasMathias

OverviewOverview

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

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

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

Role of distal embolic protection devices Role of distal embolic protection devices unclear at this timeunclear at this time

95% Left Subclavian Stenosis95% Left Subclavian Stenosis

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

Patient SelectionPatient Selection

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

Anatomic LocationsAnatomic Locations

Left Subclavian (most common)Left Subclavian (most common) BrachiocephalicBrachiocephalic Left Common Carotid OriginLeft Common Carotid Origin Right Subclavian (often in aberrant vessel)Right Subclavian (often in aberrant vessel)

IndicationsIndications

Upper Extremity IschemiaUpper Extremity Ischemia Arm ClaudicationArm Claudication Emboli from lesion to handEmboli from lesion to hand

Cerebral IschemiaCerebral Ischemia Anterior (carotid) symptomsAnterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian stealVertebro-basilar Insufficiency w/wo subclavian steal

Diminished Inflow to GraftDiminished Inflow to Graft Angina in patient with LIMAAngina in patient with LIMA Claudication in patient with Ax-femClaudication in patient with Ax-fem

DiagnosisDiagnosis

Clinical HistoryClinical History BLOOD PRESSURES in both arms – simpleBLOOD PRESSURES in both arms – simple MRAMRA CTACTA Conventional Angiography – AP and LAOConventional Angiography – AP and LAO

Diagnostic AngiographyDiagnostic Angiography

Evaluate for central lesion (stenosis/occlusion)Evaluate for central lesion (stenosis/occlusion) Evaluate for evidence of distal emboli (then do Evaluate for evidence of distal emboli (then do

echocardiography of heart)echocardiography of heart) Evaluate for vasospastic disorder, e.g., Evaluate for vasospastic disorder, e.g.,

Raynaud’s (do angio before and after Raynaud’s (do angio before and after vasodilator)vasodilator)

Evaluate for thoracic outlet syndrome (do Evaluate for thoracic outlet syndrome (do abduction and adduction angio)abduction and adduction angio)

Great Vessel Angioplasty/Stent Great Vessel Angioplasty/Stent TechniqueTechnique

Do baseline neurological examDo baseline neurological exam Initial high quality diagnostic thoracic aortagramInitial high quality diagnostic thoracic aortagram Arteriography of distal vascular beds as allowed Arteriography of distal vascular beds as allowed

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

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

but pre-dilate if lesion is too tight to get acrossbut pre-dilate if lesion is too tight to get across 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 lesionConsider primary stent based on appearance of lesion

Brachiocephalic (Innominate) Brachiocephalic (Innominate) Artery AngioplastyArtery Angioplasty

99% stenosis at originof brachiocephalic artery

Cross lesion from an axillary approach


10 mm balloon with “waist” 10 mm balloon fully inflated


Initial 99% stenosis Final with residual stenosis <30%Note post stenotic dilatation

Subclavian Stenosis proximal to Subclavian Stenosis proximal to LIMA coronary graft – no stentLIMA coronary graft – no stent

Diffuse stenosis – poor fillingof the LIMA graft

S/P Angioplasty – circa 1991

Stenosis in Single supra-aortic Stenosis in Single supra-aortic Vessel – Now What?Vessel – Now What?

Follow up – MR? CT? Angio?Follow up – MR? CT? Angio?

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

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

Stenosis within stentStenosis within stent

Bifurcation LesionsBifurcation Lesions

Can occur at right subclavian – right Can occur at right subclavian – right common carotid bifurcationcommon carotid bifurcation

Must use RAO projection to evaluate Must use RAO projection to evaluate stenosisstenosis

Options include: Options include: 1) simple angioplasty1) simple angioplasty 2) kissing balloon angioplasty2) kissing balloon angioplasty 3) simple stent3) simple stent 4) kissing stents4) kissing stents


Subclavian Steal95% stenosis in proximalright subclavian artery


Kissing balloon from femoral andright axillary approach

Final ResultExcellent is the Enemy of Good!

Bifurcation LesionBifurcation LesionPulse Volume RecordingsPulse Volume Recordings

Right Arm Left ArmFingers of Right Hand

Life Table AnalysisLife Table Analysis30 Subclavian Angioplasty Patients 30 Subclavian Angioplasty Patients

University of VirginiaUniversity of Virginia

Summary of Largest Series of PTA of Summary of Largest Series of PTA of Brachiocephalic Arterial StenosesBrachiocephalic Arterial Stenoses

-164239/305 (78%)

380/396 (96%)

396OVERALL

(30)1-(54%)21/23 (91%)23Farina et al

6-60 (25)2118/21 (86%)21/23 (91%)23Wilms et al

9-101 (41)4137/44 (84%)45/46 (98%)46Millaire et al

18-26--17/21 (81%)18/21 (86%)21Erbstein et al

8-111 (50)0017/25 (68%)23/25 (92%)25Romanowshi et al

2-90 (26)2130/34 (89%)34/34 (100%)34Insall et al

(37)11-26/29 (90%)29Burke et al

-00-35/35 (100%)35Vitek et al

8-60 (27)0016/16 (100%)16/16 (100%)16Motarjeme et al

2-73 (28)2021/22 (95%)22/22 (100%)22Dorros et al

6-48 (29)0034/43 (79%)40/43 (93%)43Hebrang et al

3-109 (58)2045/47 (96%)47/47 (100%)47Kachel et al

4-88 (36)2031/32 (97%)32/32 (100%)32Selby et al

Months Follow-up (mean)

Complications - Other

Complications – Neurologic

Clinical SuccessTechnical Success

No. of LesionsAuthors

Summary of Series of Brachiocephalic Summary of Series of Brachiocephalic Arterial OcclusionsArterial Occlusions

1936/46 (78%)68/93 (73%)93Overall

5-5/5 (100/5)5Bates

73/7 (43%)7/8 (88%)8Duber et al

732/38 (84%)38/46 (83%)46Mathias et al

01/1 (100%)1/7 (15%)7Motarjeme et al

0-11/11 (100%)11Dorros et al

0-5/9 (56%)9Hebrang et al

0-1/7 (15%)7Kachel et al

No. of Patients Receiving Stents

Clinical SuccessTechnical SuccessNo. of OcclusionsAuthors

ComplicationsComplications

Puncture site complications, femoral or Puncture site complications, femoral or brachialbrachial

Rupture of vesselRupture of vessel Emboli from angioplasty siteEmboli from angioplasty site Stent misplacementStent misplacement


Mathias, et al: 38 patients with total Mathias, et al: 38 patients with total occlusions – No significant embolic occlusions – No significant embolic occlusionsocclusions


Literature review by Kachel, et al: Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA774 supraaortic lesions treated with PTA 0.5% Major complications0.5% Major complications 3.5% Minor complications3.5% Minor complications

ExplanationsExplanations

20 second delay in restoration of antegrade flow 20 second delay in restoration of antegrade flow in vertebral artery following angioplasty – in vertebral artery following angioplasty – Ringelstein, et al, Nuclear Medicine dataRingelstein, et al, Nuclear Medicine data

Lack of clinical significance of small emboli to Lack of clinical significance of small emboli to handhand

Possible different response of large vessels to Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli angioplasty/stent (iliac vs. SFA emboli experience)experience)

Still, now we have protection Still, now we have protection devices …devices …

Landing zone for protection device in Landing zone for protection device in supra-aortic angioplasty is often vessel too supra-aortic angioplasty is often vessel too largelarge

Probably should use it when possibleProbably should use it when possible

We’re not done yet!We’re not done yet!Articles to be published in 2006Articles to be published in 2006

6 articles on results of simple angioplasty 6 articles on results of simple angioplasty and/or stenting of great vesselsand/or stenting of great vessels

3 articles on great vessel disease 3 articles on great vessel disease treatment in conjunction with thoracic treatment in conjunction with thoracic aortic stent graftaortic stent graft

2 articles on percutaneous treatment for 2 articles on percutaneous treatment for arteritisarteritis

ConclusionConclusion

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

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

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

Consider the use of distal embolic protection, Consider the use of distal embolic protection, although rate of complications has been low although rate of complications has been low without itwithout it

SummarySummary

Angioplasty of the Great Vessels can be a useful Angioplasty of the Great Vessels can be a useful treatment in a surgically difficult areatreatment in a surgically difficult area

Results mimic those of the common iliac arteries Results mimic those of the common iliac arteries (>90% success) and have further improved with (>90% success) and have further improved with the use of stents, particularly for occlusionsthe use of stents, particularly for occlusions

Improvements in technology have increased the Improvements in technology have increased the technical success in occlusionstechnical success in occlusions

Complications are low, but remain a hazard – Complications are low, but remain a hazard – consideration should be given to the use of consideration should be given to the use of distal protection devices when anatomy is distal protection devices when anatomy is suitablesuitable

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Angioplasty and Stenting of the Great Vessels