Angioplasty and Stenting of the Great Vessels

Angioplasty and Stenting of the Great Vessels: 

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

History: 

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

Overview: 

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

95% Left Subclavian Stenosis: 

95% Left Subclavian Stenosis Pre Post Post Aortagram

Left Subclavian Stenosis – Pre, Post, and 6 month follow-up: 

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

Patient Selection: 

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

Anatomic Locations: 

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

Indications: 

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

Diagnosis: 

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

Diagnostic Angiography: 

Diagnostic Angiography Evaluate for central lesion (stenosis/occlusion) 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 thoracic outlet syndrome (do abduction and adduction angio)

Great Vessel Angioplasty/Stent Technique: 

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

Great Vessel Angioplasty/Stent Technique: 

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

Brachiocephalic (Innominate) Artery Angioplasty: 

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

Brachiocephalic (Innominate) Artery Angioplasty: 

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

Brachiocephalic (Innominate) Artery Angioplasty: 

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

Subclavian Stenosis proximal to LIMA coronary graft – no stent: 

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

Stenosis in Single supra-aortic Vessel – Now What?: 

Stenosis in Single supra-aortic Vessel – Now What?

Follow up – MR? CT? Angio?: 

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

Subclavian Stenosis proximal to LIMA coronary graft – with stent: 

Subclavian Stenosis proximal to LIMA coronary graft – with stent

Stenosis within stent: 

Stenosis within stent

Bifurcation Lesions: 

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

Bifurcation Lesions: 

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

Bifurcation Lesions: 

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

Bifurcation Lesion Pulse Volume Recordings: 

Bifurcation Lesion Pulse Volume Recordings Right Arm Left Arm Fingers of Right Hand

Life Table Analysis 30 Subclavian Angioplasty Patients University of Virginia: 

Life Table Analysis 30 Subclavian Angioplasty Patients University of Virginia

Summary of Largest Series of PTA of Brachiocephalic Arterial Stenoses: 

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%) 0 2 4-88 (36) Kachel et al 47 47/47 (100%) 45/47 (96%) 0 2 3-109 (58) Hebrang et al 43 40/43 (93%) 34/43 (79%) 0 0 6-48 (29) Dorros et al 22 22/22 (100%) 21/22 (95%) 0 2 2-73 (28) Motarjeme et al 16 16/16 (100%) 16/16 (100%) 0 0 8-60 (27) Vitek et al 35 35/35 (100%) - 0 0 - Burke et al 29 26/29 (90%) - 1 1 (37) Insall et al 34 34/34 (100%) 30/34 (89%) 1 2 2-90 (26) Romanowshi et al 25 23/25 (92%) 17/25 (68%) 0 0 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%) 1 4 9-101 (41) Wilms et al 23 21/23 (91%) 18/21 (86%) 1 2 6-60 (25) Farina et al 23 21/23 (91%) (54%) - 1 (30) OVERALL 396 380/396 (96%) 239/305 (78%) 4 16 -

Summary of Series of Brachiocephalic Arterial Occlusions: 

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 Bates 5 5/5 (100/5) - 5 Overall 93 68/93 (73%) 36/46 (78%) 19

Complications: 

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

Complications: 

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

Complications: 

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

Explanations: 

Explanations 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 Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience)

Still, now we have protection devices …: 

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

We’re not done yet! Articles to be published in 2006: 

We’re not done yet! Articles to be published in 2006 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 2 articles on percutaneous treatment for arteritis

Conclusion: 

Conclusion 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 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

Summary: 

Summary 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 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