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Subclavian Artery Disease: Simulation Training Curriculum. Subclavian Artery Stenosis. Etiology Incidence Clinical manifestations Diagnosis Indications Treatment Options - PTA - Surgical Technical Issues Complications Prognosis. - PowerPoint PPT Presentation
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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