Subclavian Artery Disease: Simulation Training Curriculum

07-1

Subclavian ArteryDisease:

Simulation TrainingCurriculum

07-2

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis

Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-3

Subclavian Artery Disease: Etiology

• Atherosclerosis

• Takayasu Arteritis

• Fibromuscular dysplasia

• Giant Cell Arteritis

• Radiation-induced Vascular Injury

• Thoracic Outlet Syndrome

• Neurofibromatosis

07-4

• Most common cause of

subclavian artery stenosis

• Predilection for the proximal part

of the artery

Subclavian Artery Atherosclerosis

• The occlusion usually extends from the aortic

arch to the origin of the vertebral artery due

to poor collateral circulation

07-5

Takayasu Arteritis

• Nonspecific inflammatory disease • Primarily affects large arteries such as the aorta and

its branches • Includes both occlusive and aneurysmal disease

– Occlusive disease is more prevalent in Japan, the United States, and Europe

– Aneurysmal disease is more common in India, Thailand, Mexico, and Africa

• The prevalence is higher in women• Median age of onset varies from 25 years in Asia and

the United States to 41 years in Europe

07-6

Takayasu arteritis

presenting with subclavian aneurysm

Colvine et al Arthritis & Rheumatism (Add Year )54, 1: 382

07-7

The 1990 Criteria for Takayasu Arteritis1

1. Development of symptoms or findings related to Takayasu arteritis at age ≤40 years

2. Development and worsening of fatigue and discomfort in muscles of one or more extremities while in use, especially the upper extremities

3. Decreased pulsation of one or both brachial arteries

4. Difference of >10 mm Hg in systolic blood pressure between arms

5. Bruit audible on auscultation over one or both subclavian arteries or abdominal aorta

6. Arteriographic narrowing or occlusion of the entire aorta, its primary branches, or large arteries in the proximal upper or lower extremities, not due to arteriosclerosis, fibromuscular dysplasia, or similar causes; changes usually focal or segmental

A patient shall be said to have Takayasu arteritis if at least three of these six criteria are present. The presence of any three or more criteria yields a sensitivity of 90.5%

and a specificity of 97.8%.

Arend et al Am College of Rheum 1990; 33 :1129–1134

07-8

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis

Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-9

Subclavian Artery Stenosis: IncidenceSubclavian Artery Stenosis: Incidence

• Incidence of 0.5 - 2% 1

• Left : Right = 3-4 : 1 ratio

• The stenosis is usually focal and in the proximal segment of the vessel

• Predictors:– HTN

– Tobacco use

– Dyslipidemia

– Diabetes

1. Perrault et al, Ann Thorac Surgery 1993; 56: 927-30

07-10

The Incidence of Subclavian Stenosis in The Incidence of Subclavian Stenosis in Population Cohorts and Clinical CohortsPopulation Cohorts and Clinical Cohorts11

Prevalence (95% CI) 1.9% (1.4, 2.4) 7.1% (5.7, 8.7)

Age <50 yrs 1.4% (0.6, 2.6) N/A

Age 50–59 yrs 1.5% (0.8, 2.7) 4.3% (1.6, 9.0)‡

Age 60–69 yrs 1.7% (0.9, 2.9) 5.8% (3.8, 8.4)

Age 70+ yrs 2.7% (1.7, 4.1) 8.7% (6.6, 11.1)

1 Subclavian stenosis was defined as an interarm systolic blood pressure of ≥15 mm Hg;† there was an insufficient sample size to determine the prevalence in ages <50 years;‡ cohort C excluded individuals less than age 55.

Population Cohort (n = 2,885)

Clinical Cohort (n = 1,227)†

Shadman et al J Am Coll cardio 2004; 44:618-623

07-11

The Incidence of Subclavian Stenosis in The Incidence of Subclavian Stenosis in

Population and Clinical CohortsPopulation and Clinical Cohorts

Non-Hispanic White 2.3% 6.0%

Hispanic 1.7% 10.5%

Current or past smoker 2.2% 7.4%

Ever diabetic 1.6% 8.0%

Ever hypertensive 2.5% 8.5%

PAD 10.1% 9.3%

Ever had a stroke 2.5% 8.7%

Coronary Artery Disease 1.5% 6.0%

Population Cohort (n = 2,885)

Clinical Cohort (n = 1,227)

Shadman et al J Am Coll Cardiol 2004; 44:618-623

07-12

Subclavian Artery Disease PrevalenceSubclavian Artery Disease Prevalence

In Angiographic StudiesIn Angiographic Studies

0

5

10

15

20

25

3.5%

6.8%

19%

CABG PtsPts2

1English JE, CCI 2001;54:8

Pts with PAD Undergoing

Cardiac Cath3

3Gutierrez GR, Angiology 2001;52:1892Osborn L, CCI 2002;56:162

Cardiac CathPts1

07-13

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis

Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-14

Subclavian Steal SyndromeSubclavian Steal Syndrome The vertebral artery steals blood from the posterior The vertebral artery steals blood from the posterior

cerebral circulationcerebral circulation

Stenosis of the subclavian artery or the brachiocephalic trunk proximal to the vertebral artery origin results in low-velocity and/or retrograde flow in the ipsilateral vertebral artery distal to the subclavian artery narrowing

Wu C et al. Radiology 2005;235:927-933

07-15Bitar et al Am J Roentg 2004; 183:1840-1

Contrast-enhanced MR angiogram reveals lesion (arrow) responsible for subclavian steal syndrome is seen in left subclavian artery

07-16

Color MR AngiogramColor MR Angiogram

Retrograde flow in the left vertebral artery in a patient with a subclavian steal is shown in blue (arrows), indicating opposite flow direction. Note that the vertebral artery is red (arrowheads), indicating normal flow direction.

Aoki et al Am J Neurorad 1998; 19:691-693

07-17

Subclavian Steal SyndromeSubclavian Steal SyndromeClinical ManifestationsClinical Manifestations

• Arm claudication or hand numbness and a decrease of at least 20 mm Hg in blood pressure in the upper limb on the affected side

• Cerebral symptoms : dizziness, vertigo, and visual disturbances. In rare cases, cerebral ischemia may be present

07-18

Reversal of internal mammary artery flow

(arrows) with left upper extremity activity

Coronary IschemiaCoronary Ischemia

Takach et al Annal of Thoracic Surgery 2001, 71(1): 187-9

Coronary - Subclavian Steal SyndromeCoronary - Subclavian Steal Syndrome

07-19

Angiographic Evidence of Coronary-Subclavian Steal Syndrome

A, Angiography of the left coronary artery

and LIMA in a right anterior oblique

cranial projection. The figure is a

composite of 2 images obtained during

the same injection. The arrow points to

the subclavian artery. B, Angiography of

the left subclavian artery in an anterior-

posterior projection. C,Angiography of

the left subclavian artery in an anterior-

posterior projection after stent

placement. Vert indicates vertebral

artery.

Kroll et al Circulation. 2002;105:e184

07-20

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis

Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-21

Subclavian Artery Disease: DiagnosisSubclavian Artery Disease: Diagnosis

• Obstruction of the SA is suspected when there is a blood pressure difference > 20mm Hg between the two arms1

• If there is a clinical suggestion of vasculitis: an erythrocyte sedimentation rate (ESR) or C-Reactive protein (CRP) should be measured2

1. Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic Trunks” pg. 655-671.

2. Grossmans “Catheterization” 7th Ed. pg. 573-575

07-22

Noninvasive Diagnostic Modalities:Noninvasive Diagnostic Modalities:Duplex UltrasonographyDuplex Ultrasonography

• Duplex ultrasonography of the subclavian artery and

the vertebral artery can detect stenosis greater than

50% with a moderately high sensitivity (80% range)

and an excellent negative predictive value (> 95%)

• Duplex ultrasonography is also highly useful in

clinical follow-up of patients after revascularization

procedures

Kalaria et al J Am Soc of Echocard 2005, 18: 1107-1111

07-23

Abnormal subclavian artery duplex waveform showing elevated peak systolic velocity, spectral broadening, and loss of triphasic waveform.

Normal subclavian artery Duplex waveform

Kalaria et al J Am Soc of Echocard 2005, 18: 1107-1111

07-24

Noninvasive Diagnostic ModalitiesNoninvasive Diagnostic ModalitiesDiagnostic ImagingDiagnostic Imaging

The diagnostic imaging work-up of patients should include:- Magnetic resonance imaging (MRI) with or

without arteriography (MRA)- Computed tomographic (CT) scan of the

brain with close evaluation of the posterior

fossa and brainstream.

Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic trunks” pg. 655-671.

07-25Wu C. et al. Radiology 2005;235:927-933

A. Coronal image from MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery.

B. Transverse image from MR angiography of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow

07-26

Subclavian Artery Disease: ArteriographySubclavian Artery Disease: Arteriography

• Ascending aortography

• Selective arteriography of supra-aortic vessels

Kang WC et al. Circulation 2006;113:e735-737e

07-27

Baseline Angiogram Post Stenting Arteriogram

Queral R, Criado F J Vasc Surg 1996;23:368-75

Severe Stenosis of Left Subclavian ArterySevere Stenosis of Left Subclavian Artery

07-28

Angiograms revealing total occlusions of Angiograms revealing total occlusions of both subclavian arteriesboth subclavian arteries

07-29

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-30

Indications for RevascularizationIndications for Revascularization• Symptomatic ischemia of the posterior fossa• Symptomatic subclavian steal syndrome• Disabling upper extremity cludication• Preservation of flow to LIMA/RIMA

– Preop coronary bypass surgery, where LIMA/RIMA will be used

– Postop CABG LIMA/RIMA with ischemia (with or without coronary-subclavian steal syndrome)

• Preservation of inflow to axillary graft or dialysis conduit

• “Blue-digit” syndrome (embolization to fingers)• Inability to measure blood pressure• Progressive stenosis or thromboembolus threatening

cerebral blood supply

Grossmans “Catheterization” 7th Ed. pg. 573-575.

07-31

A. Severe stenosis in the Left Subclavian, associated with 60-mm Hg reduction in left brachial cuff pressure and B. painful embolic ulcer at fingertip.

Suclavian Artery Stenting for Blue Digit SyndromeSuclavian Artery Stenting for Blue Digit Syndrome

C. Balloon angioplasty (PTA)/stenting performed via femoral approach using 85 cm long 7F sheath. Care used to avoid vertebral origin.

D. Healed ulcer 2 months poststent.

A B

C D

Grossmans “Catheterization” 7th Ed. pg. 573-575.

07-32

Indications for Revascularization in Indications for Revascularization in Asymptomatic PatientsAsymptomatic Patients

• Angioplasty of the subclavian stenosis before other cardiovascular intervention and preservation of the vasculature for other angioplasty procedures

• Preservation of the cerebral perfusion. If other arterial lesions exist at the level of the supra-aortic vessels, to improve cerebral flow.

Farina et al Am J Surg 1989; 58:511-14

Burke et al Radiology 1987; 164:699-704

07-33

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-34

Percutaneous revascularization with balloon angioplasty followed by stent placement is the treatment of choice.

Subclavian Artery Stenosis: PTASubclavian Artery Stenosis: PTA

Debries et al J Vasc Surg 2005; 41 (1) 19-23

07-35

Subclavian Artery Stenosis: StentingSubclavian Artery Stenosis: Stenting

Prevertebral Portion of Subclavian Artery

Balloon expandable or

self expanding stents with good radial force

Postvertebral Portion of Subclavian Artery

Self expanding stents to avoid possibility of

postvertebral compression by extravascular

structures at the thoracic outlet

07-36

Subclavian Artery Stenosis: Subclavian Artery Stenosis: Stenting of Ostial SubclavianStenting of Ostial Subclavian

07-37

Left subclavian artery stenosis. a: Subclavian artery pre-stent. b: Stent placement. c: Repeat angiogram post-stent placement.

Subclavian Artery Stenosis: StentingSubclavian Artery Stenosis: Stenting

Amor et al Cathet Cardiovasc Interv 2004; 63: 364-370

07-38

Indications for Covered Stents

• Aneurysm or “pseudoaneurysm”• Traumatic artery injury• Spontaneous arterial rupture or dissection

Heuser R, Biamino G. Peripheral Vasc Stenting.2nd Ed. Pg:154

07-39

Subclavian Artery Stenosis: Subclavian Artery Stenosis: PTA Initial Success RatePTA Initial Success Rate

Motarjeme A J of Endovascular Surgery 1996 3: 171–181

07-40

Associated Vertebral Artery StenosisAssociated Vertebral Artery Stenosis

• Kissing balloon technique

• Complication: brain embolization

• Cerebral protection devices, protection balloons, or filters could be used.

07-41

Subclavian Artery Stenosis: SurgerySubclavian Artery Stenosis: Surgery

Takach et al Annal of Thoracic Surgery 2001; 71: 187-9

Revascularization of the subclavian artery using extrathoracic (carotid-subclavian)

bypass.

• Carotid-subclavian

bypass

• Aortosubclavian

bypass

• Axilloaxillary bypass

07-42

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-43

Subclavian Artery StenosisSubclavian Artery StenosisAnticoagulationAnticoagulation

• Premedication with Aspirin, with optional addition of clopidogrel

• Anticoagulation for a period of several weeks prior to revascularization in cases of Subclavian occlusion

Grossmans “Catheterization” 7th Ed. pg. 573-575.

07-44

Femoral Approach

It is used at first intention in the majority of the cases

07-45

Subclavian Artery Stenosis

Femoral Approach

8 Fr quiding catheter0.035’’ steerable or hydrophilic guide wire

0.018’’ – 0.020’’ steerable guide wire

Success Failure

Isolated stenosis

Predilatation

Good result Insufficient result

Stent

Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic trunks” pg. 655-671.

Brachial approach

Surgery

Primary stenting

Adjacent to vertebral Artery

2 steerable guide wires(Vertebral 0.014’’, subclavian 0.018’’)

Kissing balloon angioplasty

Good result Insufficient result

Stent

07-46

Brachial ApproachBrachial Approach

• Recanalization of an occluded

Subclavian artery (SA)

• When the occlusion begins at

the ostium of the SA

• Severe tortuosity of the aorta

• Iliac and subclavian artery

• Bilateral occlusion of the iliac

arteries Queral R, Criado F J Vasc Surg 1996;23:368-75.)

Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic trunks” pg. 655-671.

07-47

Subclavian Artery Stenosis

First Approach Brachial Approach After failure of FemoralApproach

6 or 7 Fr long introduceur quiding catheter0.035’’ steerable or hydrophilic guide wire0.018’’ – 0.020’’ steerable guide wire

Success Failure

Primary stenting Predilatation Femoral Approach

Good result Insufficient result

Surgery

Failure Success

Stent

Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic trunks” pg. 655-671.

07-48

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-49

Subclavian Artery Stenting:Subclavian Artery Stenting:ComplicationsComplications

• Hematomas• Subclavian thrombosis• Axillary artery thrombosis• Stent Migration• Arterial rupture• Dissection• Distal embolization• Restenosis• Neurologic complications

– Transient ischemic attack , stroke, hemiplegia, diplopia.

07-50

Arterial RuptureArterial Rupture

A B

07-51

Stent MigrationStent Migration

07-52

ThrombusThrombus

07-53

Dissection

07-54

Subclavian Artery StenosisSubclavian Artery Stenosis

Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options

- PTA- Surgical

Technical Issues Complications Prognosis

07-55

Favorable PredictorsFavorable Predictors

• Presence of subclavian steal syndrome : it

prevents the risk of vertebral embolization 1

• Isolatated stenosis

• Recurrent angina following an internal

mammary coronary bypass 2,3

1. Hennerici et al Neurology 1988; 38: 669-6732. Diethrich et al J Endovasc Surg 1995; 2: 77-803. Marques et al J cardiol 1996; 78: 687-690

07-56

Percutaneous transluminal angioplasty appears safe and efficient therapy for subclavian artery stenoses is not only an effective initial treatment, but also successful over the short- and long-term results.

Subclavian Artery Stenosis: OutcomeSubclavian Artery Stenosis: Outcome

07-57

Subclavian Artery Stenting: PTA Follow UpSubclavian Artery Stenting: PTA Follow Up n % Immediate results (0-30 days)    Number at risk 89   Primary patency 88 98.88   Restenosis within 30 days 0 0.00   Deaths within 30 days 1 1.12Midterm results (> 30 days to <2 years)   Number at risk 88   Primary patency 75 85.23   Restenosis 5 5.68   Deaths 8 9.09Long-term results (> 2 years)   Number at risk 75   Primary patency 62 82.67   Restenosis 8 10.67   Deaths 5 6.67Minimum observation time (months) 0.46Maximum observation time (months) 109.43Mean observation time (months) 36.12 ± 30.39

Bates et al Cath Cardiovasc Interv 2003; 61 (1):5-11

07-58

Cumulative patency was 89% at 40 months (n = 28), which is consistent with current literature. At 72 months, patency was 66% (n = 11); at 98.29 months, 57% (n = 1). Mean average follow-up time was 36.12 ± 30.39 months

Cumulative PatencyCumulative Patency

Bates et al Cath Cardiovasc Interv 2003 61 (1) Pages: 5-11

07-59

Patient Survival TimePatient Survival Time

Bates et al Cath Cardiovasc Interv 2003 61 (1) Pages: 5-11

Cumulative patient survival (actual survival time) was 93% at 12 months (n = 65), 88% at 24 months (n = 47), 69% at 85 months (n = 8) and for the remainder of the 9-year follow-up

07-60

Six months after the two stents were implanted, flow through the subclavian revascularization site is excellent; however, intimal hyperplasia has developed within the vertebral stent, although flow is not significantly hindered

Henry et al J endovasc therapy 1999;6 (1): 33-41

07-61

Direct Stenting Vs. PredilatationDirect Stenting Vs. Predilatation

Amor et al cath cardiovasc interv 2004; 63 (3): 364-370

07-62

Life Tables for All Patients Treated Without Stents in the Subclavian Artery

Henry et al J endovasc therapy 1999;6 (1): 33-41

07-63

Life Tables for All Patients Treated With Stents in the Subclavian Artery

Henry et al J endovasc therapy 1999;6 (1): 33-41