Angioplasty and Stenting of the Great Vessels

Institut fur Diagnostische und Interventionelle Radiologie Universitat Frankfurt am Main June 7, 2006

J. Bayne Selby, Jr., MD Medical University of South Carolina

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

95% Left Subclavian Stenosis

Pre

Post

Post Aortagram

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

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

Upper Extremity Ischemia

Arm Claudication Emboli from lesion to hand Anterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian steal

Cerebral Ischemia

Diminished Inflow to Graft

Angina in patient with LIMA Claudication in patient with Ax-fem

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)

Great Vessel Angioplasty/Stent Technique

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)

Great Vessel Angioplasty/Stent Technique

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

Brachiocephalic (Innominate) Artery Angioplasty

99% stenosis at origin of brachiocephalic artery

Cross lesion from an axillary approach

Brachiocephalic (Innominate) Artery Angioplasty

10 mm balloon with waist

10 mm balloon fully inflated

Brachiocephalic (Innominate) Artery Angioplasty

Initial 99% stenosis

Final with residual stenosis <30% Note post stenotic dilatation

Subclavian Stenosis proximal to LIMA coronary graft no stent

Diffuse stenosis poor filling of the LIMA graft

S/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 Lesions

Can occur at right subclavian right common carotid bifurcation Must use RAO projection to evaluate stenosis Options include:

1) 2) 3) 4)

simple angioplasty kissing balloon angioplasty simple stent kissing stents

Bifurcation Lesions

95% stenosis in proximal right subclavian artery

Subclavian Steal

Bifurcation Lesions

Kissing balloon from femoral and right axillary approach

Final Result Excellent is the Enemy of Good!

Bifurcation Lesion Pulse Volume Recordings

Fingers of Right Hand Right Arm Left Arm

Life Table Analysis 30 Subclavian Angioplasty Patients University of Virginia

Summary of Largest Series of PTA of Brachiocephalic Arterial Stenoses

Authors Selby et al Kachel et al Hebrang et al Dorros et al Motarjeme et al Vitek et al Burke et al Insall et al Romanowshi et al Erbstein et al Millaire et al Wilms et al No. of Lesions 32 47 43 22 16 35 29 34 25 21 46 23 Technical Success 32/32 (100%) 47/47 (100%) 40/43 (93%) 22/22 (100%) 16/16 (100%) 35/35 (100%) 26/29 (90%) 34/34 (100%) 23/25 (92%) 18/21 (86%) 45/46 (98%) 21/23 (91%) Clinical Success 31/32 (97%) 45/47 (96%) 34/43 (79%) 21/22 (95%) 16/16 (100%) 30/34 (89%) 17/25 (68%) 17/21 (81%) 37/44 (84%) 18/21 (86%) Complications Neurologic 0 0 0 0 0 0 1 1 0 1 1 Complications Other 2 2 0 2 0 0 1 2 0 4 2 Months Followup (mean) 4-88 (36) 3-109 (58) 6-48 (29) 2-73 (28) 8-60 (27) (37) 2-90 (26) 8-111 (50) 18-26 9-101 (41) 6-60 (25)

Farina et al
OVERALL

23
396

21/23 (91%)
380/396 (96%)

(54%)
239/305 (78%)

1
16

(30)
-

Summary of Series of Brachiocephalic Arterial Occlusions

Authors Kachel et al Hebrang et al Dorros et al Motarjeme et al Mathias et al Duber et al Bates Overall No. of Occlusions 7 9 11 7 46 8 5 93 Technical Success 1/7 (15%) 5/9 (56%) 11/11 (100%) 1/7 (15%) 38/46 (83%) 7/8 (88%) 5/5 (100/5) 68/93 (73%) Clinical Success 1/1 (100%) 32/38 (84%) 3/7 (43%) 36/46 (78%) No. of Patients Receiving Stents 0 0 0 0 7 7 5 19

Complications

Puncture site complications, femoral or brachial Rupture of vessel Emboli from angioplasty site Stent misplacement

Complications

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

Complications

Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA

0.5% Major complications 3.5% Minor complications

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)

Still, now we have protection devices

Landing zone for protection device in supra-aortic angioplasty is often vessel too large Probably should use it when possible

Were not done yet! Articles to be published in 2006

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