1. Subclavian, Innominate & Vertebral Artery Treatment
SOFIA - BEC 2012
Subclavian, Innominate & Vertebral Artery Treatment
K. Mathias
Department of Radiology
Klinikum Dortmund / Germany

2. Indications for Subclavian & Innominate Artery Revascularization
Symptomatic posterior ischemia
Symptomatic subclavian steal syndrome
Disabling upper extremity claudication
Preservation of flow into LIMA/RIMA grafts
Preservation of inflow to axillary graft or dialysis conduit
Embolization to the fingers from subclavian disease (e.g., “Blue-digit” syndrome)
We treat exclusively
symptomatic patients !

3. Vessel Sizes of Upper Extremity Arteries
Size (mm)
Brachiocephalic (innominate)
8-12
Subclavian
6- 10
Vertebral
4- 7
Axillary
5- 7
Brachial
3- 4
Radial & Ulnar

4. Technique of Endovascular Treatment
Access
femoral
brachial
radial
carotid
Sheath
6 to 8 French
Guiding catheter
6 to 8 French

5. Technique of Endovascular Tx of Stenoses
Access
femoral
brachial
radial
carotid
Probing of stenosis nearly always possible

6. Technique of Endovascular Tx of Stenoses
Stents
balloon expandable
oversize <2 mm
pre-dilatation in severe and
calcified lesions
Don‘t push too hard or the stent will be moved to the shaft of the catheter

7. Technique of Endovascular Tx of Occlusions
Access
femoral
brachial
radial
carotid
More pushing force - easier crossing

8. Subclavian Artery Stenosis
Subclavian Steal Syndrome
T.N. f- 61y
Omnilink 1.8 x 8 mm

9. Bilateral Subclavian Artery Stenosis
Risk:
undetected
hypertension
GH m-62

10. Right Subclavian A. Occlusion
arm weakness
vertigo
RG m-57

11. Innominate Artery Occlusion
weak radial pulse right
hand
vertigo
2x drop attacks
combined femoral and
brachial access

12. Innominate Artery Occlusion
MT m-42
Express stent 10x18 mm

13. Innominate Artery Occlusion
MT m-42

14. Subclavian & Carotid Artery Stenosis
Symptoms:
81 yo female with a high grade stenosis of the internal carotid artery on both sides and a proximal stenosis of the left subclavian artery with a subclavian-steal-syndrome.
Cardiovascular risk factors:
high blood pressure, diabetes mellitus
Medical history:
CAD, renal dysfunction due to diabetic nephropathy serum creatinine 2.9 mg/dl

15. MRA Findings

16. Combined Tx

17. Combined Tx

18. Innominate Artery Stenosis
CABG
arm weakness
vertigo
KM f-82

19. Revascularization of left CCA and SA
Aortic Arch Syndrome
Revascularization of left CCA and SA
FW m-58

20. Aortic Arch Syndrome Innominate artery occlusion Left cca occlusion
Left subclavian artery occlusion
Right vertebral artery occlusion
Left vertebral artery stenosis

21. Aortic Arch Syndrome
Recanalization of innominate artery improved flow of:
right carotid artery
collaterals to right proximally occluded VA

22. Coronary Steal Syndrome
C.F. f-75 Angina 3 yrs after CABG
Coro: normal anastomosis, but ..

23. Coronary Steal Syndrome
C.F. f-75 Angina 3 yrs after CABG
Coro: normal anastomosis, but retrograde flow in the mamarian artery

24. Coronary Steal Syndrome
C.F. f-75 Angina 3 yrs after CABG - Orthograde flow in the mamarian artery restored - chest pain disappeared immediately !

25. What do we achieve with endovascular treatment
of aortic arch arteries?

26. Tx of Subclavian & Innominate Arteries
417 patients with stenting in 497 lesions*
Indications:
arm ischemia (54%)
subclavian steal (37%)
coronary-subclavian steal (19%)
planned CABG with IMA (7%)
TIA (6%)
*Dortmund data

27. Tx of Subclavian & Innominate Arteries
Success rates:
100% for stenoses
91% for occlusions
One fatal hemorrhagic stroke (0.4%)
*Dortmund data

28. Tx of Subclavian & Innominate Arteries
At 3 years of F/U:
asymptomatic 82%
primary patency 86%
secondary patency 96%
*Dortmund data

29. Tx of Subclavian & Innominate Arteries
Recurrent disease
Re-occlusion after 11 months:
insufficient primary tx
stent to short and
not fully deployed
FW m-58

30. Balloon Angioplasty vs. Stenting of Subclavian Artery Obstruction
Retrospective analysis in 107 patients
Mean age years, 90% symptomatic
Procedure: PTA alone (n=14), stenting (n=90) with balloon-expandable (n=61), self-expandable (n=17), or both (n=12)
Follow-up based on oscillometry, Doppler BP measurements, and Duplex ultrasound
Sixt S, Zeller T et al. Catheter Cardiovasc Interv 2009;73(3):

31. Balloon Angioplasty vs. Stenting of Subclavian Artery Obstruction
One year patency rate:
79% PTA
89% stenting (P=0.2)
Endovascular therapy has excellent acute success rates and good durability with a trend towards better outcome with stenting compared to PTA
Sixt S, Zeller T et al. Catheter Cardiovasc Interv 2009;73(3):

32. Percutaneous Angioplasty of Subclavian Arteries
237 patients with SA
stenosis n=192
occlusion n= 45
Procedure:
PTA n= 59
balloon-expandable stent n=132
self-expandable stent n= 32
Henry M et al. Int Angiol ;26(4):

33. Percutaneous Angioplasty of Subclavian Arteries
Success rate:
all 94%
occlusion 69%
Periprocedural events: 1.2%
(1 major stroke, 1 TIA, 2 arterial thrombosis)
At 5 years: restenosis rate 12%
after PTA %
after stenting %
Henry M et al. Int Angiol ;26(4):

34. Percutaneous Angioplasty of Subclavian Arteries
Percutaneous angioplasty is the treatment of choice for subclavian artery lesions. Stents reduce the restenosis rate and improve long-term results.
Henry M et al. Int Angiol ;26(4):

35. Angioplasty of the Innominate Artery
89 patients with symptomatic high-grade (>60%) innominate artery stenosis
F/U by BP measurement and duplex scan
Primary success rate: 96.4%
Complications: 4 TIA, 2 puncture site thrombosis, 1 occipital lobe infarction
Huttl K, et al. Cardiovasc Intervent Radiol 2002;25(2):

36. Angioplasty of the Innominate Artery
Restenosis: 2 patients treated with re-PTA
Patency rate:
primary 93%,
secondary 98%
at months
PTA of innominate artery is safe and effective and should be the treatment of choice for a stenotic lesion or short occlusion.
Huttl K, et al. Cardiovasc Intervent Radiol 2002;25(2):

37. Stenting of Subclavian & Innominate Artery
Stenting of subclavian and innominate artery lesions resulted in durable midterm effect.
Brountzos EN, et al. Cardiovasc Intervent Radiol 2004;27:616-23

38. PTA vs. Surgery for Proximal Subclavian Artery Lesions
74 patients
SPTA 40 pts
SCT 34 pts
subclavian-to-carotid artery transposition
Subclavian occlusion:
62% in SPTA (n=40)
73% in SCT (n=34)
Other risk factors comparable in both groups
Linni K, et al. Ann Vasc Surg ;22(6):

39. PTA vs. Surgery for Proximal Subclavian Artery Lesions
All SCTs were successful
sPTA can be performed successfully by
surgeons, however, failed in 48% of occlusions!
Primary sPTA is recommended for SA stenosis and surgery for SA occlusions.
Linni K, et al. Ann Vasc Surg ;22(6):

40. PTA/Stent vs. Carotid-subclavian Bypass for Subclavian Artery Disease
PTA/stent (n=121)
CSBG
(n=51)
P-value
Technical success
100%
98% NS
Periop complication
15% 6%
0.093
Primary patency*
1 year
93%
5 years
70%
96%
Both CSBG using PTFE grafts and PTA/stenting are safe and effective; however, CSBG is more durable in the long term.
AbuRahma AF, et al. J Endovasc Ther 2007;14:

41. PTA/Stent vs. Surg of Subclavian Aa
Technical
Success
Stroke
Death
Complications
Recurrence
Hadjipetrou P et al. J Am Coll Cardiol 1999;33:

42. Conclusions Angioplasty and stenting of aortic arch arteries
is successful in %
Recurrence rate %, but re-do possible
Clinical success %
No randomized trials - individual tx decisions