Overview of Subclavian & Innominate Artery Interventions

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1 TCT 2016 Washington, DC, USA Tuesday November 1st, 2016 Peripheral vascular interventions Overview of Subclavian & Innominate Artery Interventions Dr Jacques Busquet Vascular & Endovascular Surgery Paris, France Val d Or

2 Disclosure None Related to this presentation TCT 2016

3 Subtotally occluded calcified ostial left subclavian artery Accessible to endovascular revascularization

4 Subtotally occluded calcified ostial left subclavian artery Accessible to endovascular revascularization Femoral Access

5 Subtotally occluded calcified ostial left subclavian artery Brachial Access Accessible to percutaneous endovascular revascularization

6 Supra-aortic truncks Left Subclavian Artery

7 Innominate Artery Supra-aortic truncks

8 Angio CT 3D Reconstruction

9 Duplex Scan Examination

10 Transcranial examination

11 Arterial Supra-Aortic Truncks 20% Distribution of Atheromatous Disease 20% Fields WS, Lemak NA. Joint study of extracranial arterial occclusion JAMA 1972; 222:

12 Severe Proximal Innominate Artery Stenosis

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14 Angioplasty & Stenting of Innominate Artery Open Retrograde Access with Clamping of Common Carotid Artery for Cerebral Protection

15 Subclavian Artery Occlusive Disease

16 Fischer CM A New Vascular Syndrome the Subclavian Steal N Engl J Med 1961;265:

17 Subclavian Steal Definition Severe Stenosis or Occlusion of Pre-Vertebral Subclavian Artery Reversed Flow in Vertebral Artery with Re-Injection of Subclavian Artery

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19 Subclavian Steal Syndrome Non-Predictive of Neurovascular Events Marker of Atheromatous Disease Hennevici M, Klemm C, Rantengerg W The Sub-Clavian Steal Phenomenon: A Common Vascular Disorder with Rare Neurologic Deficit Neurology 1988;38:

20 Hemodynamic Sequence Subclavian Steal

21 Subclavian Steno-Thrombosis

22 Reversed Vertebral Flow

23 Subclavian Re-Injection

24 Surgical Revascularization Subclavian Artery Transversal Cervicotomy Carotido-Subclavian Transposition Carotido-Subclavian Bypass Inomminate Artery Sternotomy Aorto-Inomminate Artery Bypass Endarterectomy

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26 Kieffer E, Sabatier J, Koskas F, Bahnini A Atherosclerotic Innominate Artery Occlusive Disease: Early and Long-Term Results of Surgical Reconstruction J Vasc Surg 1995 ; 21 : patients operated for atherosclerotic lesions of supra-aortic truncks over a period of 20 years Post-operative mortality was 5.4% Survival rate was 77.5% at 5 years and 51.9% at 10 years follow-up Late mortality is essentially caused by myocardial infarction (12% of the cases).

27 Laurian C, Cron J, Gigou C et al Atherosclerotic Lesions of the Subclavian Artery: Role of the Carotid-Subclavian Arterial Transposition J Mal Vasc 1998 ; 23 : Carotido-subclavian transposition with a global patency rate of 96% at 5 years follow-up is justified as a first-choice technique in the treatment of subclavian artery obstructions

28 Carotid-Subclavian Direct Surgical Transposition Common Carotid Vertebral Artery Subclavian Artery

29 Operative Risks Coronary Risk Lymphatic Risk Left Subclavian Artery Neurologic Risk Right Subclavian Artery

30 Balloon Angioplasty First Case Report Bachman DM, Kim RM Transluminal Dilatation for Subclavian Steal Syndrome AJR Am J Roentgenol 1980;135:

31 Angioplasty & Stenting Motarjeme A. Percutaneous transluminal angioplasty of supra-aortic vessels. J Endovasc Surg. 1996;3: Criado FJ, Queral L. The role of angioplasty and stenting in the treatment of occlusive lesions of supra-aortic truncks. J Mal Vasc. 1996;21: Rodriguez-Lopez JA, Werner R, Toruella L, Ray L, Diethrich EB. Stenting of atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg 1999;13:

32 Subclavian Steal 3 Steps Permanent Steal Reversed Vertebral Flow Intermittent Steal Biphasic Flow Pre-Steal Test of Hyperhemia

33 Symptoms Cervical bruit No radial pulse Arm-to-arm BP difference 20-30mmHg Paresthesia of upper limb Induced with arm exercice Dizziness Drop attack Syncope

34 Case # 1 62 years old woman Light tabagism 2 years follow-up Progressive Subclavian Stenosis 60% 80% Anisotension Vertigo > Syncope Right arm claudication

35 Anatomical Variant Arteria Lusoria 80% Prevertebral Proximal Stenosis

36 Arteria Lusoria Intermittent Right Subclavian Steal

37 Arteria Lusoria Intermittent Right Subclavian Steal

38 Arteria Lusoria Intermittent Right Subclavian Steal

39 Arteria Lusoria Intermittent Right Subclavian Steal

40 Humeral puncture Local Anesthesia Long Sheath Heparinization

41 Angiographic Confirmation of the Lesion

42 Primary Stenting with balloon 7mm/40mm

43 Post Procedural Angiographic Control

44 Case report # 2 79 years old woman Autonomous Recurrent Syncopes Normal Cerebral CT Normal Electrophysiology Initial Duplex Scan Underestimated

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52 Restenosis Rate From 4.5 to 14.6% Follow up 14 to 36 months V.M. Ochoa et al, Vascular Medecine 2010,16 1: 29-34

53 Subclavian Coronary Steal Syndrome Diethrich EB, Cozacov JC. Subclavian stent implantation to alleviate coronary steal through a patent internal mammary artery graft. J Endovasc Surg 1995;2:77-80 Left Subclavian Angioplasty to restore coronary flow in the affected LIMA graft

54 LSA Branch Thoracic Stent Graft Frank Arko III, MD, Charlotte, NC, USA

55 Conclusion Role of Duplex Scan Surveillance of Asymptomatic Lesions Indications for Surgical Revascularization Transposition or bypass Endovascular Techniques Humeral Percutaneous Access Short Inflation - Vertebral Protection A new deal regarding anatomical fixation of thoracic endograft

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