1. Angioplasty and Stenting of the Great Vessels J. Bayne Selby, Jr., MD Medical University of South Carolina Institut fur Diagnostische und Interventionelle Radiologie Universitat Frankfurt am Main June 7, 2006

2. History 1964 First angioplasty report by Dotter and Judkins 1964 First angioplasty report by Dotter and Judkins 1980 First subclavian angioplasty report by Bachman and Kim 1980 First subclavian angioplasty report by Bachman and Kim 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary bypass graft 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary bypass graft 1993 First subclavian stent use reported by Mathias 1993 First subclavian stent use reported by Mathias

3. Overview Stenoses/occlusion in the great vessels usually represent difficult areas to access surgically Stenoses/occlusion in the great vessels usually represent difficult areas to access surgically Results with angioplasty have been uniformly good in stenoses Results with angioplasty have been uniformly good in stenoses Use of stents has resulted in similar results for complete occlusions Use of stents has resulted in similar results for complete occlusions Role of distal embolic protection devices unclear at this time Role of distal embolic protection devices unclear at this time

4. 95% Left Subclavian Stenosis Pre Post Post Aortagram

5. Left Subclavian Stenosis – Pre, Post, and 6 month follow-up Pre Immediate Post 6 months post

6. Patient Selection As always, treatment should only be performed in those patients who have both a hemodynamically significant lesion and appropriate corresponding symptoms As always, treatment should only be performed in those patients who have both a hemodynamically significant lesion and appropriate corresponding symptoms

7. Anatomic Locations Left Subclavian (most common) Left Subclavian (most common) Brachiocephalic Brachiocephalic Left Common Carotid Origin Left Common Carotid Origin Right Subclavian (often in aberrant vessel) Right Subclavian (often in aberrant vessel)

8. Indications Upper Extremity Ischemia Upper Extremity Ischemia Arm Claudication Arm Claudication Emboli from lesion to hand Emboli from lesion to hand Cerebral Ischemia Cerebral Ischemia Anterior (carotid) symptoms Anterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian steal Vertebro-basilar Insufficiency w/wo subclavian steal Diminished Inflow to Graft Diminished Inflow to Graft Angina in patient with LIMA Angina in patient with LIMA Claudication in patient with Ax-fem Claudication in patient with Ax-fem

9. Diagnosis Clinical History Clinical History BLOOD PRESSURES in both arms – simple BLOOD PRESSURES in both arms – simple MRA MRA CTA CTA Conventional Angiography – AP and LAO Conventional Angiography – AP and LAO

10. Diagnostic Angiography Evaluate for central lesion (stenosis/occlusion) Evaluate for central lesion (stenosis/occlusion) Evaluate for evidence of distal emboli (then do echocardiography of heart) Evaluate for evidence of distal emboli (then do echocardiography of heart) Evaluate for vasospastic disorder, e.g., Raynaud’s (do angio before and after vasodilator) Evaluate for vasospastic disorder, e.g., Raynaud’s (do angio before and after vasodilator) Evaluate for thoracic outlet syndrome (do abduction and adduction angio) Evaluate for thoracic outlet syndrome (do abduction and adduction angio)

11. Great Vessel Angioplasty/Stent Technique Do baseline neurological exam Do baseline neurological exam Initial high quality diagnostic thoracic aortagram Initial high quality diagnostic thoracic aortagram Arteriography of distal vascular beds as allowed by degree of disease Arteriography of distal vascular beds as allowed by degree of disease First attempt to cross lesion from below First attempt to cross lesion from below Use brachial approach if necessary Use brachial approach if necessary Give Heparin once lesion has been crossed (2,000-3,000 units) Give Heparin once lesion has been crossed (2,000-3,000 units)

12. Great Vessel Angioplasty/Stent Technique Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, smile, wiggle toes) Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, smile, wiggle toes) Use guiding catheter or sheath 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 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 Leave balloon up for 10 seconds Stent for >30% residual stenosis, dissection, recoil Stent for >30% residual stenosis, dissection, recoil Consider primary stent based on appearance of lesion Consider primary stent based on appearance of lesion

13. Brachiocephalic (Innominate) Artery Angioplasty 99% stenosis at origin of brachiocephalic artery Cross lesion from an axillary approach

14. Brachiocephalic (Innominate) Artery Angioplasty 10 mm balloon with “waist”10 mm balloon fully inflated

15. Brachiocephalic (Innominate) Artery Angioplasty Initial 99% stenosis Final with residual stenosis <30% Note post stenotic dilatation

16. Subclavian Stenosis proximal to LIMA coronary graft – no stent Diffuse stenosis – poor filling of the LIMA graft S/P Angioplasty – circa 1991

17. Stenosis in Single supra-aortic Vessel – Now What?

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

19. Subclavian Stenosis proximal to LIMA coronary graft – with stent

20. Stenosis within stent

21. Bifurcation Lesions Can occur at right subclavian – right common carotid bifurcation Can occur at right subclavian – right common carotid bifurcation Must use RAO projection to evaluate stenosis Must use RAO projection to evaluate stenosis Options include: Options include: 1) simple angioplasty 1) simple angioplasty 2) kissing balloon angioplasty 2) kissing balloon angioplasty 3) simple stent 3) simple stent 4) kissing stents 4) kissing stents

22. Bifurcation Lesions Subclavian Steal 95% stenosis in proximal right subclavian artery

23. Bifurcation Lesions Kissing balloon from femoral and right axillary approach Final Result Excellent is the Enemy of Good!

24. Bifurcation Lesion Pulse Volume Recordings Right ArmLeft Arm Fingers of Right Hand

25. Life Table Analysis 30 Subclavian Angioplasty Patients University of Virginia

26. Summary of Largest Series of PTA of Brachiocephalic Arterial Stenoses Authors No. of Lesions Technical Success Clinical Success Complications – Neurologic Complications - Other Months Follow- up (mean) Selby et al 32 32/32 (100%) 31/32 (97%) 02 4-88 (36) Kachel et al 47 47/47 (100%) 45/47 (96%) 02 3-109 (58) Hebrang et al 43 40/43 (93%) 34/43 (79%) 00 6-48 (29) Dorros et al 22 22/22 (100%) 21/22 (95%) 02 2-73 (28) Motarjeme et al 16 16/16 (100%) 00 8-60 (27) Vitek et al 35 35/35 (100%) -00- Burke et al 29 26/29 (90%) -11(37) Insall et al 34 34/34 (100%) 30/34 (89%) 12 2-90 (26) Romanowshi et al 25 23/25 (92%) 17/25 (68%) 00 8-111 (50) Erbstein et al 21 18/21 (86%) 17/21 (81%) --18-26 Millaire et al 46 45/46 (98%) 37/44 (84%) 14 9-101 (41) Wilms et al 23 21/23 (91%) 18/21 (86%) 12 6-60 (25) Farina et al 23 21/23 (91%) (54%)-1(30) OVERALL396 380/396 (96%) 239/305 (78%) 416-

27. Summary of Series of Brachiocephalic Arterial Occlusions Authors No. of Occlusions Technical Success Clinical Success No. of Patients Receiving Stents Kachel et al 7 1/7 (15%) -0 Hebrang et al 9 5/9 (56%) -0 Dorros et al 11 11/11 (100%) -0 Motarjeme et al 7 1/7 (15%) 1/1 (100%) 0 Mathias et al 46 38/46 (83%) 32/38 (84%) 7 Duber et al 8 7/8 (88%) 3/7 (43%) 7 Bates5 5/5 (100/5) -5 Overall93 68/93 (73%) 36/46 (78%) 19

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

29. Complications Mathias, et al: 38 patients with total occlusions – No significant embolic occlusions Mathias, et al: 38 patients with total occlusions – No significant embolic occlusions

30. Complications Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA 0.5% Major complications 0.5% Major complications 3.5% Minor complications 3.5% Minor complications

31. Explanations 20 second delay in restoration of antegrade flow in vertebral artery following angioplasty – Ringelstein, et al, Nuclear Medicine data 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 Lack of clinical significance of small emboli to hand Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience) Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience)

32. Still, now we have protection devices … Landing zone for protection device in supra-aortic angioplasty is often vessel too large Landing zone for protection device in supra-aortic angioplasty is often vessel too large Probably should use it when possible Probably should use it when possible

33. We’re not done yet! Articles to be published in 2006 6 articles on results of simple angioplasty and/or stenting of great vessels 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 3 articles on great vessel disease treatment in conjunction with thoracic aortic stent graft 2 articles on percutaneous treatment for arteritis 2 articles on percutaneous treatment for arteritis

34. Conclusion Angioplasty, with or without stenting is highly effective for stenoses of the great vessels 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 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 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 Consider the use of distal embolic protection, although rate of complications has been low without it

35. Summary Angioplasty of the Great Vessels can be a useful treatment in a surgically difficult area 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 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 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 Complications are low, but remain a hazard – consideration should be given to the use of distal protection devices when anatomy is suitable