Ann Thorac Surg 2007;84:688-689
© 2007 The Society of Thoracic Surgeons
How To Do It
New Subclavian Artery Angioplasty Technique for Treating Subclavian Coronary Steal Syndrome
Gianluca Rigatelli, MD*,
Paolo Cardaioli, MD,
Massimo Giordan, MD,
Stefano Panin, RN,
Susanna Ferro, RN,
Loris Roncon, MD
Interventional Cardiology Unit, Angiographic Pole, Rovigo General Hospital, Verona, Italy
Accepted for publication November 9, 2006.
* Address correspondence to Dr Rigatelli, Section of Peripheral and Congenital Heart Interventions, Interventional Cardiology Unit, Rovigo General Hospital, Via Mozart 9, Legnago, Verona, 37048, Italy (Email: jackyheart{at}hotmail.com).
 |
Abstract
|
|---|
Left subclavian artery stenting is usually performed through the standard femoral route using a guiding catheter technique. This technique has obvious drawbacks in the case of coronary subclavian steal due to the poor opacification of the left internal mammary artery (LIMA) ostium, and difficult access to the LIMA in the case of plaque shifting, especially when the vertebral artery and the LIMA ostia are very close to the left subclavian artery stenosis. We have developed an "ad hoc" technique to minimize catheter manipulation and contrast injection, and to optimize LIMA and vertebral artery visibility during stent implantation, which includes access through the brachial artery and a long sheath guiding catheter. This technique should be preferred to the standard femoral route because of its intrinsic advantages.
|
Introduction
|
|---|
Due to the rather high rate of peripheral vascular atherosclerotic distributions, especially involving the supraaortic vessels [1], patients who undergo coronary bypass grafting using the left internal mammary artery (LIMA) may have a coronary subclavian steal syndrome develop because of left subclavian artery (LSA) stenosis. The LSA stenting is usually performed using a catheter guiding technique through the standard femoral route, but this technique has clear drawbacks in the case of coronary subclavian steal due to the poor opacification of the LIMA ostium, and difficult access to the LIMA with plaque shifting, especially when the vertebral artery and the LIMA ostia are in close proximity to the LSA stenosis [2].
We decided to use the brachial artery approach as the optimal route for endovascular LSA stenting in patients with coronary-subclavian syndrome because this ad hoc technique minimizes catheter manipulation and contrast injection, as well as optimizing LIMA and the vertebral artery visibility during stent implantation.
|
Technique
|
|---|
Between January 2005 and September 2006, 4 consecutive patients (mean age, 68 ± 9.8 years; mean stenosis severity, 91.7 ± 14.5%) underwent LSA angioplasty and stenting of the subclavian artery for coronary-subclavian steal syndrome using this novel technique. Instrumental indications for the procedure were anginal symptoms or acute coronary syndrome (ie, acute myocardial infarction in 1 patient and non-ST elevation acute coronary syndrome in 3 patients) with induced myocardial ischemia during a stress echocardiography or evidence of the same, or both (ie, in 3 patients), or stress scintigraphy (ie, in 1 patient) with no LIMA or native anterior descending coronary artery disease. Informed consent was obtained from all patients. The LSA stenting was performed through the left brachial artery with a 6-French or 7-French 45 cm-long valved anti-kinking sheath such as the Super Arrow Flex sheath (Arrow International, Reading, PA). Insertion of the long sheath was monitored under fluoroscopy as it moved forward to the subclavian artery ostium. The diameter of the sheath was chosen to allow for sufficient contrast volume to be injected through the sheath itself when the balloon catheter was also inside during stent deployment. A hydrophilic anti-kinking sheath (ie, such as those made by Arrow or Cook) is preferable to minimize arterial damage. The sheath was positioned just before the LIMA graft ostium and a 0.035-inch 260-cm long Storq guidewire (Cordis Inc, Johnson & Johnson, Warren, NJ) was moved across the lesion to the descending aorta. A 6 x 29 mm (2 patients) or a 7 x 39 mm (2 patients) balloon-expandable Genesis (Cordis Inc, Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed and correct positioning was confirmed by direct contrast injection through the long sheath (Figs 1A,
1B). After the procedure all patients were given aspirin (100 mg/day) plus ticlopidin (250 mg twice a day). Follow-up included examinations at 3, 6, and 12 months and stress tests (ie, treadmill test or nuclear stress test) at 6 and 12 months. The implanted stent was monitored by Doppler ultrasonography examination or angiographic magnetic resonance imaging at 6 and 12 months.
View larger version (98K):
[in this window]
[in a new window]
|
Fig 1. Tight subclavian artery stenosis in a 70-year-old female patient. (A) Basal angiography: the stenosis is in close proximity to the left internal mammary artery (LIMA) and vertebral artery (VERT) origin (arrows). (B) Final result after angioplasty and stenting: the LIMA and vertebral artery are perfectly patent.
|
|
The procedure was successful in all patients and no cerebral or peripheral embolisms were noted after angioplasty and stenting of the left subclavian artery (mean final stent diameter, 7.6 ± 0.56 mm). Correct visualization of LIMA and vertebral artery ostia was accomplished in all patients as well as the correct deployment of the stent at the lesion site (Fig 1). Vertebral and LIMA ostia remained patent in all cases. No brachial artery vascular complications including spasm, hematoma, pseudoaneurysm, or rupture were noted. Troponin T and Creatine phosphokinase-MB remained at basal level after the procedure in all patients. Mean pre-treatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg, which fell to 2 mm Hg with a range of 0 to 4 mm Hg post-treatment (p < 0.01). Mean contrast dose was 60 ± 16 mL, whereas mean fluoroscopy and procedural times were 5.7 ± 1.6 minutes and 15.7 ± 6.3 minutes. At a mean follow-up of 10 ± 3.2 months all patients are alive and free from angina and residual induced ischemia. On clinical and instrumental examination no evident thrombosis or re-stenosis has been documented in the implanted vascular stents.
|
Comment
|
|---|
Subclavian artery angioplasty and stenting is quite a safe and effective procedure for treating coronary subclavian steal syndrome with a good primary clinical patency at 2 years of 79%, an assisted patency rate of 79%, and a 30-day mortality rate of 9.5% [3]. The current strategy for performing LSA angioplasty includes the use of the femoral approach and a guiding catheter to selectively cannulate the LSA ostium and support stent placement [4]. This strategy may have some drawbacks such as excessive manipulation of the catheter to cannulate the subclavian ostia, poor visibility of the vertebral artery and LIMA during stent positioning, difficulty in engaging the LIMA or vertebral artery for embolic protection or angioplasty in the case of LIMA or vertebral coverage or plaque shifting.
Our technique suggests that the brachial artery approach may be the best route for treating coronary subclavian steal syndrome because of the clear advantages, including no manipulation of the catheter to cannulate the artery, perfect coaxial positioning of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, easy access to these vessels in the case of plaque shifting, or embolic protection device deployment. Moreover, the procedure was accomplished with a minimum quantity of contrast medium and similar stenosis visualization as when accessed through the standard femoral route. We believe that this technique should be regarded as the preferential technique for treating coronary subclavian steal syndrome whenever there are no contraindications to the brachial approach.
|
Acknowledgments
|
|---|
The authors gratefully thank Professor Anne Holdstock for her help in editing the manuscript.
|
References
|
|---|
- Rigatelli G, Rigatelli G. Simultaneous preoperative brachiocephalic angiography and coronary angiography to prevent coronary-subclavian steal syndrome in coronary surgery candidates Heart Surg Forum 2005;8:E175-E177.[Medline]
- Ribichini F, Maffe S, Ferrero V, Cotroneo A, Vassanelli C. Percutaneous angioplasty of the subclavian artery in patients with mammary-coronary bypass grafts J Interv Cardiol 2005;18:39-44.[Medline]
- Angle JF, Matsumoto AH, McGraw JK, et al. Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up Vasc Endovascular Surg 2003;37:89-97.[Abstract/Free Full Text]
- Filippo F, Francesco M, Francesco R, et al. Percutaneous angioplasty and stenting of left subclavian artery lesions for the treatment of patients with concomitant vertebral and coronary subclavian steal syndrome Cardiovasc Intervent Radiol 2006;29:348-353.[Medline]
Top
Abstract
Introduction
