Angioplasty and Stenting of the Great Vessels J. Bayne Selby, Jr., MD Medical University of South Carolina Institut fur Diagnostische und Interventionelle

Angioplasty and Stenting Angioplasty and Stenting of the Great Vesselsof the 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 1964 First angioplasty report by Dotter and Judkinsand Judkins

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

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

1993 First subclavian stent use reported 1993 First subclavian stent use reported by Mathiasby Mathias

OverviewOverview

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

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

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

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

95% Left Subclavian 95% Left Subclavian StenosisStenosis

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 performed in those patients who have both a hemodynamically have both a hemodynamically significant lesion and appropriate significant lesion and appropriate corresponding symptomscorresponding 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 Right Subclavian (often in aberrant

vessel)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 Vertebro-basilar Insufficiency w/wo subclavian

stealsteal 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 – BLOOD PRESSURES in both arms –

simplesimple MRAMRA CTACTA Conventional Angiography – AP and Conventional Angiography – AP and

LAOLAO

Diagnostic AngiographyDiagnostic Angiography

Evaluate for central lesion Evaluate for central lesion (stenosis/occlusion)(stenosis/occlusion)

Evaluate for evidence of distal emboli Evaluate for evidence of distal emboli (then do echocardiography of heart)(then do 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 Initial high quality diagnostic thoracic

aortagramaortagram Arteriography of distal vascular beds as Arteriography of distal vascular beds as

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

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

dilatation, but pre-dilate if lesion is too tight to get dilatation, but pre-dilate if lesion is too tight to get acrossacross

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 Consider primary stent based on appearance of

lesionlesion

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

stentstent

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

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

stentstent

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 Arm

Fingers 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

AuthorsAuthors No. of LesionsNo. of Lesions Technical Technical SuccessSuccess

Clinical Clinical SuccessSuccess

ComplicationComplications – s – NeurologicNeurologic

ComplicationComplications - Others - Other

Months Months Follow-up Follow-up (mean)(mean)

Selby et alSelby et al 3232 32/32 (100%)32/32 (100%) 31/32 (97%)31/32 (97%) 00 22 4-88 (36)4-88 (36)

Kachel et alKachel et al 4747 47/47 (100%)47/47 (100%) 45/47 (96%)45/47 (96%) 00 22 3-109 (58)3-109 (58)

Hebrang et alHebrang et al 4343 40/43 (93%)40/43 (93%) 34/43 (79%)34/43 (79%) 00 00 6-48 (29)6-48 (29)

Dorros et alDorros et al 2222 22/22 (100%)22/22 (100%) 21/22 (95%)21/22 (95%) 00 22 2-73 (28)2-73 (28)

Motarjeme et Motarjeme et alal

1616 16/16 (100%)16/16 (100%) 16/16 (100%)16/16 (100%) 00 00 8-60 (27)8-60 (27)

Vitek et alVitek et al 3535 35/35 (100%)35/35 (100%) -- 00 00 --

Burke et alBurke et al 2929 26/29 (90%)26/29 (90%) -- 11 11 (37)(37)

Insall et alInsall et al 3434 34/34 (100%)34/34 (100%) 30/34 (89%)30/34 (89%) 11 22 2-90 (26)2-90 (26)

Romanowshi Romanowshi et alet al

2525 23/25 (92%)23/25 (92%) 17/25 (68%)17/25 (68%) 00 00 8-111 (50)8-111 (50)

Erbstein et alErbstein et al 2121 18/21 (86%)18/21 (86%) 17/21 (81%)17/21 (81%) -- -- 18-2618-26

Millaire et alMillaire et al 4646 45/46 (98%)45/46 (98%) 37/44 (84%)37/44 (84%) 11 44 9-101 (41)9-101 (41)

Wilms et alWilms et al 2323 21/23 (91%)21/23 (91%) 18/21 (86%)18/21 (86%) 11 22 6-60 (25)6-60 (25)

Farina et alFarina et al 2323 21/23 (91%)21/23 (91%) (54%)(54%) -- 11 (30)(30)

OVERALLOVERALL 396396 380/396 380/396 (96%)(96%)

239/305 239/305 (78%)(78%)

44 1616 --

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

AuthorsAuthors No. of OcclusionsNo. of Occlusions Technical SuccessTechnical Success Clinical SuccessClinical Success No. of Patients No. of Patients Receiving StentsReceiving Stents

Kachel et alKachel et al 77 1/7 (15%)1/7 (15%) -- 00

Hebrang et alHebrang et al 99 5/9 (56%)5/9 (56%) -- 00

Dorros et alDorros et al 1111 11/11 (100%)11/11 (100%) -- 00

Motarjeme et alMotarjeme et al 77 1/7 (15%)1/7 (15%) 1/1 (100%)1/1 (100%) 00

Mathias et alMathias et al 4646 38/46 (83%)38/46 (83%) 32/38 (84%)32/38 (84%) 77

Duber et alDuber et al 88 7/8 (88%)7/8 (88%) 3/7 (43%)3/7 (43%) 77

BatesBates 55 5/5 (100/5)5/5 (100/5) -- 55

OverallOverall 9393 68/93 (73%)68/93 (73%) 36/46 (78%)36/46 (78%) 1919

ComplicationsComplications

Puncture site complications, femoral Puncture site complications, femoral or brachialor brachial

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 774 supraaortic lesions treated with PTAPTA 0.5% Major complications0.5% Major complications 3.5% Minor complications3.5% Minor complications

ExplanationsExplanations

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

Lack of clinical significance of small emboli Lack of clinical significance of small emboli to handto hand

Possible different response of large vessels Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli to 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 supra-aortic angioplasty is often vessel too largevessel too large

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 Articles to be published in

20062006 6 articles on results of simple 6 articles on results of simple

angioplasty and/or stenting of great angioplasty and/or stenting of great vesselsvessels

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

2 articles on percutaneous treatment 2 articles on percutaneous treatment for arteritisfor arteritis

ConclusionConclusion

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

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

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

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

SummarySummary

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

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

Improvements in technology have increased Improvements in technology have increased the technical success in occlusionsthe technical 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

Documents

Angioplasty and Stenting of the Great Vessels J. Bayne Selby, Jr., MD Medical University of South Carolina Institut fur Diagnostische und Interventionelle