Endovascular therapy of subclavian artery occlusive disease involving the vertebral artery origin
Abstract
Summary. Background: While the majority of subclavian artery (SA) lesions are localized in the proximal segment, the evidence in patients with medial SA disease involving the vertebral artery (VA) origin are scarce. Patients and methods: We retrospectively analyzed all patients who underwent percutaneous revascularization of the SA at our institution. Results: A total of 196 patients were retrospectively analyzed. The majority of SA lesions (n = 163, 83 %) were located in the proximal segment, whereas 28 lesions (14 %) were located in the medial segment, and only 5 lesions (3 %) involved the distal segment. Procedural success was high for both stenosis (96 %) and occlusion (89 %) and did not differ depending on lesion location. Revascularization techniques in the medial segment included stenting of the SA only (13 patients), additional VA balloon-dilatation (6 patients), and bifurcation stenting of the SA and VA using T-stenting technique (9 patients). Outcome after a median of 12 months showed no significant differences in freedom from restenosis between proximal and medial lesions (90 % vs. 95 %; p = 0.67). Conclusions: Endovascular revascularization of SA disease with medial segments involving the VA origin required more complex techniques and showed long-term patency rates comparable to those in lesions located within the proximal SA.
References
1 . Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv. 2001;54:8–11.
2 Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases. J Am Coll Cardiol. 2004;44:618–23.
3 . Unilateral digital ischaemia secondary to embolisation from subclavian atheroma. Ann R Coll Surg Engl. 1989;71:140–2.
4 . Joint Study of extracranial arterial occlusion. VII. Subclavian steal–a review of 168 cases. JAMA. 1972;222:1139–43.
5 . Review of coronary-subclavian steal following internal mammary artery-coronary artery bypass surgery. Ann Thorac Surg. 1988;46:675–8.
6 . Percutaneous transluminal stent placement to treat subclavian steal syndrome. J Vasc Interv Radiol. 1996;7:351–6.
7 Angioplasty and stenting versus carotid-subclavian bypass for the treatment of isolated subclavian artery disease. J Endovasc Ther. 2007;14:698–704.
8 . The surgical reconstruction of the proximal subclavian and vertebral artery. J Vasc Surg. 1985;2:634–42.
9 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763–816.
10 Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg. 2005;41:19–23.
11 Determinants of long-term outcome in patients after percutaneous stent-assisted management of symptomatic subclavian or innominate artery stenosis or occlusion. EuroIntervention. 2017;13:1355–64.
12 Results after balloon angioplasty or stenting of atherosclerotic subclavian artery obstruction. Catheter Cardiovasc Interv. 2009;73:395–403.
13 Outcome of conservative versus interventional treatment of subclavian artery stenosis. J Endovasc Ther. 2002;9:139–46.
14 . Long-term results of primary stenting for subclavian artery disease. Catheter Cardiovasc Interv. 2013;82:696–700.
15 . Angioplasty alone versus angioplasty and stenting for subclavian artery stenosis – a systematic review and meta-analysis. Am J Ther. 2013;20:520–3.
16 Physical properties of endovascular stents: an experimental comparison. J Vasc Interv Radiol. 2000;11:645–54.
17 Simultaneous vertebral and subclavian artery stenting. Postepy Kardiol Interwencyjnej. 2017;13:142–9.
18 Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: case series and review of the literature. J Vasc Surg. 2006;43:1145–54.
19 . A systematic review of stenting and angioplasty of symptomatic extracranial vertebral artery stenosis. Stroke. 2011;42:2212–6.
20 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. J Am Coll Cardiol. 2011;57:1002–44.
21 2-year outcome of patients treated for bifurcation coronary disease with provisional side branch T-stenting using drug-eluting stents. JACC Cardiovasc Interv. 2008;1:358–65.
22 . Commentary: vertebral artery ostial stenosis stenting technique: the concept reversed? J Endovasc Ther. 2015;22:445–8.
23 Comparison of long-term clinical and angiographic outcomes following implantation of bare metal stents and drug-eluting stents in aorto-ostial lesions. Am J Cardiol. 2011;108:1055–60.
24 . Bare metal vs. drug-eluting stents for extracranial vertebral artery disease: a meta-analysis of nonrandomized comparative studies. J Endovasc Ther. 2014;21:683–92.
25 . Stenting of vertebral artery origin atherosclerosis in high-risk patients: bare or coated? A single-center consecutive case series. J Invasive Cardiol. 2008;20:14–20.
26 Treatment of stenoses of vertebral artery origin using short drug-eluting coronary stents: improved follow-up results. AJNR Am J Neuroradiol. 2009;30:1653–6.
27 Editor’s Choice – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55:3–81.