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Institut fur Diagnostische und Interventionelle Radiologie Universitat Frankfurt am Main June 7, 2006
History
1964 First angioplasty report by Dotter and Judkins 1980 First subclavian angioplasty report by Bachman and Kim 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary bypass graft 1993 First subclavian stent use reported by Mathias
Overview
Stenoses/occlusion in the great vessels usually represent difficult areas to access surgically Results with angioplasty have been uniformly good in stenoses Use of stents has resulted in similar results for complete occlusions Role of distal embolic protection devices unclear at this time
Pre
Post
Post Aortagram
Pre
Immediate Post
6 months post
Patient Selection
As always, treatment should only be performed in those patients who have both a hemodynamically significant lesion and appropriate corresponding symptoms
Anatomic Locations
Left Subclavian (most common) Brachiocephalic Left Common Carotid Origin Right Subclavian (often in aberrant vessel)
Indications
Arm Claudication Emboli from lesion to hand Anterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian steal
Cerebral Ischemia
Diagnosis
Clinical History BLOOD PRESSURES in both arms simple MRA CTA Conventional Angiography AP and LAO
Diagnostic Angiography
Evaluate 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)
Do baseline neurological exam Initial high quality diagnostic thoracic aortagram Arteriography of distal vascular beds as allowed by degree of disease First attempt to cross lesion from below Use brachial approach if necessary Give Heparin once lesion has been crossed (2,000-3,000 units)
Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, smile, wiggle toes) Use guiding catheter or sheath Try to use appropriate ballon size for initial dilatation, but pre-dilate if lesion is too tight to get across Leave balloon up for 10 seconds Stent for >30% residual stenosis, dissection, recoil Consider primary stent based on appearance of lesion
Peloschek P., et al. The Role of Multi-slice Spiral CT Angiography in Patient Management After Endovascular Therapy. Cardiovascular and Interventional Radiology, In Press
Bifurcation Lesions
Can occur at right subclavian right common carotid bifurcation Must use RAO projection to evaluate stenosis Options include:
1) 2) 3) 4)
Bifurcation Lesions
Subclavian Steal
Bifurcation Lesions
Farina et al
OVERALL
23
396
21/23 (91%)
380/396 (96%)
(54%)
239/305 (78%)
1
16
(30)
-
Complications
Puncture site complications, femoral or brachial Rupture of vessel Emboli from angioplasty site Stent misplacement
Complications
Complications
Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA
Explanations
20 second delay in restoration of antegrade flow in vertebral artery following angioplasty Ringelstein, et al, Nuclear Medicine data Lack of clinical significance of small emboli to hand Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience)
Landing zone for protection device in supra-aortic angioplasty is often vessel too large Probably should use it when possible
6 articles on results of simple angioplasty and/or stenting of great vessels 3 articles on great vessel disease treatment in conjunction with thoracic aortic stent graft 2 articles on percutaneous treatment for arteritis
Conclusion
Angioplasty, with or without stenting is highly effective for stenoses of the great vessels Occlusive disease in the great vessels should always be treated with stent Long term result are excellent (70-90%), but follow up with CTA upon return of symptoms may be necessary Consider the use of distal embolic protection, although rate of complications has been low without it
Summary
Angioplasty of the Great Vessels can be a useful treatment in a surgically difficult area Results mimic those of the common iliac arteries (>90% success) and have further improved with the use of stents, particularly for occlusions Improvements in technology have increased the technical success in occlusions Complications are low, but remain a hazard consideration should be given to the use of distal protection devices when anatomy is suitable