Shigeyuki Sakamoto, Yoshihiro Kiura, Takahito Okazaki, Nobuhiko Ichinose, Kaoru Kurisu

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1 Journal of Cerebrovascular and Endovascular Neurosurgery pissn , eissn , Case Report Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary rtery ypass Grafting Due to Right Subclavian rtery Origin Stenosis Shigeyuki Sakamoto, Yoshihiro Kiura, Takahito Okazaki, Nobuhiko Ichinose, Kaoru Kurisu Department of Neurosurgery, Hiroshima University Graduate School of iomedical and Health Sciences, Kasumi, Minami-ku, Hiroshima, Japan Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CG) using the internal thoracic artery (IT). Subclavian artery (S) stenosis proximal to the IT graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right S origin stenosis after CG. 64-year-old man with a history of CG using the right IT presented with exertional right arm claudication. ngiogram showed a CSS and retrograde blood flow in the right vertebral artery (V) due to severe stenosis of the right S origin. Endovascular treatment of the right S stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the S proximal to the origin of the right V and IT through the right brachial artery approach and distal filter protection of the right internal carotid artery (IC) through the left femoral artery (F) approach were performed. Endovascular stenting for S stenosis from the right F approach was performed under cardiac and cerebral protection by filter-protection of the IC and balloon-protection of the V and IT. Successful treatment of S severe stenosis was achieved with no complications. Keywords Endovascular procedures, Stenosis, Stent, Subclavian artery, Subclavian steal syndrome J Cerebrovasc Endovasc Neurosurg March;17(1):27-31 Received : 26 November 2014 Revised : 28 January 2015 ccepted : 4 February 2015 Correspondence to Shigeyuki Sakamoto Department of Neurosurgery, Hiroshima University Graduate School of iomedical and Health Sciences, Kasumi, Minami-ku, Hiroshima , Japan Tel : Fax : sakamoto@hiroshima-u.ac.jp ORCID : This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non- Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CG) using the internal thoracic artery (IT). Subclavian artery (S) stenosis proximal to the IT graft may cause CSS. 2)4)6) Endovascular treatment for S stenosis has been reported with high technical and clinical success rates and with low complication rates. 8) lthough the use of cerebral protection devices in endovascular stenting for extracranial internal carotid artery (IC) stenosis is established, the use of cerebral protection devices in an endovascular stenting for S stenosis is less well established. 7)8)15) We performed endovascular stenting for S stenosis under filter-protection of the IC and balloon-protection at the right S proximal to the V and IT origin during S stenting for right S stenosis with CSS. We describe a technique for simultaneous cardiac and cerebral protection during endovascular stenting for right S origin stenosis in a pa- Volume 17 Number 1 March

2 STENTING FOR SUCLVIN STEL FTER CG Fig. 1. () Computed tomography angiography shows severe stenosis with calcification in the right subclavian artery origin (arrow) and poor visualization of the right internal thoracic artery graft (arrowheads). () Left vertebral angiography shows retrograde blood flow in the right vertebral artery. tient with CSS after CG. flow in the right IT. The patient preferred endovascular treatment rather than surgery; therefore, we plan- CSE REPORT ned to perform endovascular stenting for S stenosis. The patient was already receiving clopidogrel (75 mg 64-year-old man who had undergone CG us- daily) and aspirin (100 mg daily) orally due to a past ing the bilateral ITs and the right gastroepiploic ar- history of percutaneous coronary intervention with tery presented with exertional right arm claudication. drug-eluting stents and bare metal stents. In comparison of the arms, he had a difference in sys- The endovascular procedure was performed under tolic blood pressure of approximately 30 mmhg local anesthesia. n activated clotting time of more (right, 96/64 mmhg; left, 125/69 mmhg). He had no than 300 seconds was maintained by intravenous ad- neurological deficits or cardiac symptoms. Computed ministration of heparin. 4-Fr 90 cm sheath (FUUKI tomography (CT) angiography showed severe stenosis sheath: sahi Intecc, ichi, Japan) was navigated into with calcification in the right S origin and poor vis- the right common carotid artery through the left fem- ualization of the right IT (Fig. 1). Left vertebral an- oral artery (F) approach. For protection of the right giography showed retrograde blood flow in the right IC, a filter-wire (FilterWire EZ: oston Scientific, V (Fig. 1). ngiography showed 90% stenosis in Natick, M, US) was deployed into the right IC the right S origin and no antegrade blood flow in through the 4-Fr femoral sheath (Fig. 2). 5-Fr 11 cm the vertebral artery (V) or right IT graft secondary sheath was inserted into the right brachial artery (). to severe stenosis of the right S origin (Fig. 2). To perform protection of the right V and IT, a 5.2-Fr Right subclavian angiography showed to-and fro blood occlusion balloon catheter (Selecon MP Catheter II: 28 J Cerebrovasc Endovasc Neurosurg

3 SHIGEYUKI SKMOTO ET L C D Fig. 2. () Preoperative angiography shows 90% stenosis in the right subclavian artery origin (arrow). () The filter-wire (arrow) is deployed into the right internal carotid artery through the 4-Fr femoral sheath. 5.2-Fr occlusion balloon catheter is navigated into the subclavian artery proximal to the origin of the right vertebral artery and internal thoracic artery through the right brachial sheath, and is then inflated (double arrows). (C) The 7 27 mm balloon-expandable stent is deployed to the subclavian artery origin stenosis (asterisk). (D) Postoperative angiogram shows excellent dilatation. Terumo Clinical Supply, Gifu, Japan) was navigated in the aspirated blood, the 5.2-Fr occlusion balloon into the S proximal to the origin of the right V catheter was deflated. The occlusion catheter and fil- and IT through the right brachial sheath. 6-Fr 90 ter-wire were retrieved. Debris was not observed in cm sheath (FUUKI sheath: sahi Intecc, ichi, the filter-wire. ngiography showed excellent dilata- Japan) was positioned at the innominate artery (I) tion after stenting and antegrade blood flow in the through the right F approach, and a inch stiff right V and through the right IT graft (Fig. 2D). type 300-cm guidewire was navigated into the. fter the procedure, intravenous administration of 5.2-Fr occlusion balloon catheter at the S proximal to heparin was terminated, and argatroban was ad- the origin of the right V and IT was inflated (Fig. ministered for 12 hr. Postoperative diffusion-weighted 2). Under filter-protection of the IC and bal- images showed no hyper-intensity lesions. The patient loon-protection of the V and IT for simultaneous was discharged with no new neurological deficits or cardiac and cerebral protection, predilation was per- chest symptoms. Follow-up CT angiography at 3 formed using a 6 20 mm PT balloon. Next, a 7 months showed good patency of the S stent and 27 mm balloon-expandable stent (Express Vascular good visualization of the right IT graft (Fig. 3). LD: oston Scientific) was deployed to the S stenosis (Fig. 2C). fter stent deployment, 30 ml of blood was aspirated through the 5.2-Fr occlusion balloon catheter using a 50 ml syringe. fter no debris was confirmed DISCUSSION Protection against distal embolic complications is Volume 17 Number 1 March

4 STENTING FOR SUCLVIN STEL FTER CG Fig. 3. () Follow-up computed tomography (CT) angiography at 3 months shows stent deployment in the right subclavian artery origin (asterisk) and good visualization of the right internal thoracic artery graft (arrowheads). () Follow-up CT angiography at 3 months shows a good patency of the stent in the subclavian artery (arrow). important during endovascular treatment. lthough ter predilation. cerebral protection during extracranial IC stenting is CSS, which was first described in 1974, can be caused established, cerebral protection during S stenting by retrograde or insufficient blood flow through an has not yet been established. The reported neuro- IT graft. Proximal stenosis of the S was the most logical complication rate of S angioplasty ranges frequent cause.2)4)6) Incidence up to 3.4% after CG from 0.4 to 4.7%.7) Ringelstein and Zeumer9) used con- was reported.2)5) The treatment for CSS was thoracotomy tinuous ultrasound monitoring to observe V blood with aortosubclavian bypass, carotid subclavian bypass flow of the S stenosis or occlusion with subclavian graft, and, more recently, angioplasty and stenting.10)13) steal syndrome before, during, and after PT. The Endovascular treatment in CSS due to S stenosis af- flow direction within the V did not immediately ter CG has already been reported, and endovascular change to antegrade but rather did so gradually with- therapy with PT and stenting appeared to be an ef- in 20 s to several minutes. Therefore, they concluded fective treatment for CSS due to S stenosis.2)6)10)13)14) that this delay of flow-reversal served as a protective On the other hand, cardiac and cerebral protection mechanism against cerebral embolism during PT during S stenting in CSS was not performed.2)6)10)13)14) only. If PT or direct stenting for S stenosis with lthough native coronary stent angioplasty is per- subclavian steal was performed, embolic protection formed with no distal embolic protection, the cardiac may not be necessary. However, S stenting after complication rate during S angioplasty in CSS is predilation required distal embolic protection because unknown. On the other hand, the cerebral protection V blood flow changed to the antegrade direction af- methods during stenting for stenosis of the right S 30 J Cerebrovasc Endovasc Neurosurg

5 SHIGEYUKI SKMOTO ET L origin or I proximal to the right S origin have been reported. The anterior circulation was protected by placing a filter-wire or balloon protection device in the IC, and the posterior circulation was protected by inflating the balloon of the catheter at the S or by placing a filter-wire or balloon protection device in the V. 1)3)11)12) Therefore, we think that cardiac and cerebral protection should be performed simultaneously during S stenting for CSS as well as the right S origin or I. In the current case, we performed protection of the right IC, V, and IT for cerebral and cardiac protection. IC protection was performed to protect against distal embolization by plaque shift from the S origin. We used a filter-wire for IC protection to maintain antegrade flow. Stenting after predilation may result in distal embolization when retrograde flow in right V and IT changes into antegrade flow after predilation, therefore, right V and IT protection was performed. We used a balloon catheter for V and IT protection to induce retrograde flow in V and IT and to aspirate blood through the lumen of the balloon catheter. CONCLUSION Filter-protection of the IC and balloon-protection of the V and IT provided cardiac and cerebral protection when stenting right S stenosis in a patient with CSS after CG. Disclosure These authors report no conflict of interest in the funding, financial support, and industry affiliations. REFERENCES 1. lbuquerque FC, hmed, Mitha, Stiefel M, McDougall CG. Endovascular recanalization of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and an argument for embolic protection. World Neurosurg Dec;80(6):e icknell CD, Subramanian, Wolfe JH. Coronary subclavian steal syndrome. Eur J Vasc Endovasc Surg Feb;27(2): Guimaraes M, Muhlert MK, Enterkin J, Schönholz C. Can we provide complete cerebral protection during innominate artery stenting? J Endovasc Ther Oct;17(5): Harjola PT, Valle M. The importance of aortic arch or subclavian angiography before coronary reconstruction. Chest Oct;66(4): Lobato E, Kern K, auder-heit J, Hughes L, Sulek C. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc nesth Dec;15(6): Machado C, Raposo L, Leal S, Gonçalves P, Mesquita Gabriel H, Teles RC, et al. Coronary-subclavian steal syndrome: percutaneous approach. Case Rep Cardiol. 2013; 2013: Michael TT, anerjee S, rilakis E. Subclavian artery intervention with vertebral embolic protection. Catheter Cardiovasc Interv Jul;74(1): Miyakoshi, Hatano T, Tsukahara T, Murakami M, rai D, Yamaguchi S. Percutaneous transluminal angioplasty for atherosclerotic stenosis of the subclavian or innominate artery: angiographic and clinical outcomes in 36 patients. Neurosurg Rev Jan;35(1):121-5; discussion Ringelstein E, Zeumer H. Delayed reversal of vertebral artery blood flow following percutaneous transluminal angioplasty for subclavian steal syndrome. Neuroradiology. 1984;26(3): Sadek MM, Ravindran, Marcuzzi DW, Chisholm RJ. Complete occlusion of the proximal subclavian artery post-cg: presentation and treatment. Can J Cardiol Jul;24(7): Sakamoto S, Kiura Y, Kajihara Y, Mukada K, Kurisu K. Endovascular stenting of symptomatic innominate artery stenosis under distal balloon protection of the internal carotid and vertebral artery for cerebral protection: a technical case report. cta Neurochir (Wien) Feb;155(2): Shah N, Nee LM, Raval N. Percutaneous revascularization of subclavian artery chronic occlusion with dual cerebral artery protection. Catheter Cardiovasc Interv Jun:71(7): Tortoledo F, Sánchez, Izaguirre L, Guerrero J, Trujillo MH. Endovascular repair of symptomatic coronary-subclavian steal syndrome due to stenosis of the proximal left subclavian artery. Cardiol Rev May-Jun;13(3): Westerband, Rodriguez J, Ramaiah VG, Diethrich E. Endovascular therapy in prevention and management of coronary-subclavian steal. J Vasc Surg Oct;38(4): ; discussion Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen T, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med Oct;351(15): Volume 17 Number 1 March