Contemporary management of brachiocephalic occlusive disease. TM Sullivan Minneapolis, MN

Transcription

1 Contemporary management of brachiocephalic occlusive disease TM Sullivan Minneapolis, MN

2 WL Gore & Associates Disclosures Meeting organizer (SOAR) CR Bard Chair, CEC Bolster trial Veryan National PI, MIMICS trial (SFA stent) Allina Health Employed physician

3 INDICATIONS FOR BRACHIOCEPHALIC REVASCULARIZATION Subclavian / innominate arteries Upper extremity exercise-induced ischemia Digital / cerebral embolization Symptomatic steal Vertebral steal with VBI Coronary-subclavian steal (IMA) Pre-CABG -- inflow for IMA Inflow for subclavian <--> carotid bypass

4 INDICATIONS FOR BRACHIOCEPHALIC REVASCULARIZATION Common carotid artery Asymptomatic critical stenosis Symptomatic stenosis TIA Amaurosis fugax Prior stroke with minimal residua In conjunction with carotid bifurcation lesion Endarterectomy PTA / stent

5 CAROTID-SUBCLAVIAN BYPASS Author n Success Mort Fail F/U Diethrich % 4.8% 7% 9-14y Vogt % 0% 14% 1-11y Ziomek % 2.7% 18% 4.3y Perler % 0% 8% 5y Fry % 5% 0% 4y

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7 Transposition

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13 Berguer et al Cervical reconstruction of the supra-aortic trunks: A 16-year experience JVS 1999;29:239-48

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16 CCA L Subclavian L Vert

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19 Berguer et al Transthoracic repair of innominate and common carotid artery disease: Immediate and long-term outcome for 100 consecutive surgical reconstructions JVS 1998;27:34-42.

20 Aortic arch 30 deg LAO

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22 SUBCLAVIAN PTA Author n Success Recur F/U Becker % 19%? Hebrang % 9% 29m Duber % 63%? Selby % 3% 36m Mathias % 11% 33m Millaire % 14% 41m

23 PTA or Stent? Author N Tech success Long-term patency Ahmed 1726 >stent p=0.007 No difference Chatterjee 544 > stent > stent, p=0.004 devries % 5 years Burihan (Cochrane) No evidence that stents superior Cardiovasc Intervent Radiol 2016;39:652 (meta-analysis) AmJ Ther 2013;20:520. (meta-analysis) J Vasc Surg 2005;41:19. Cochrane Database Syst Rev 2011

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28 Queral, Criado JVS 1996;23:

29 High-grade innominate Stenosis with steal

30 Right CCA cutdown.035-in wire occludes lesion 9 Fr sheath across lesion

31 Retrograde CCA intervention via cutdown Confirm wire in true lumen Pre-dilate with sheath Tack dissection with stent Carotid / Aortic jxn

32 87 procedures in 83 patients BRACHIOCEPHALIC PTA - STENT 73 subclavian / innominate arteries 14 left common carotid arteries Access for intervention Subclavian / innominate arteries: 57% femoral 33% brachial 10% both Common carotid arteries 13 of 14 via common carotid cutdown Sullivan et al JVS 1998

33 BRACHIOCEPHALIC PTA - STENT RESULTS Initial technical success 94.3% 93.9% of 66 subclavian arteries 100% of 7 innominate arteries 92.9% of 14 common carotid arteries Technical failures: Inability to cross 4 complete subclavian occusions Iatrogenic dissection of 1 common carotid lesion (converted immediately to C-SC transposition)

34 BRACHIOCEPHALIC PTA - STENT Complications 7% - access-site 2.3% technical (stent covering origin of L vertebral) 3% other ( non-q MI, temporary ARF, CHF) Iatrogenic CCA dissection 3 (3.4%) 2 of 14 CCA interventions CVA Mortality at 30 days 4.8% (4 of 83 patients) 2 following CABG 1 from acute mesenteric ischemia / DIC 1 from massive CVA following CCA stent / re-do CEA

35 BRACHIOCEPHALIC PTA + STENT % patent % patent Sullivan, etal JVS 1998

36 CCA interventions: 10 of 11 stroke-free with normal PE and NIVL exam at mean 14.3 mos

37 False aneurysm, ascending Aorta from prior bypass

38 Left subclavian occlusion Left CCA stenosis Innominate occlusion

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45 Combined proximal stent + CEA Author N CVA Patency Sullivan % (1) 100% Arko % 100% (24 mos) Garg % 91% (C-SC bypass) Sfyroeras (meta) 1.5% 92% (12-24 mos) Clouse % (2) 96% (30 mos) J Vasc Surg 1998;28:1059 J Cardiovasc Surg 2000;41:737 Vasc Endovasc Surg 2011;45:527 J Vasc Surg 2011;54:534 J Vasc Surg 2016;63:1517

46 Covered stents? dutoit et al J Vasc Surg 2008;47:739 Stent-graft treatment of SCA trauma 57 patients over a 10-year period Etiology: 53 stab wounds 4 GSW One death: MSOF 3/57: early graft occlusion (Rx: endovascular) 25 patients followed for 48 months (mean) 5/25: restenosis 3/25: occlusion No limb loss, no surgical conversions

47 83 y.o. male Chest pain following UTI w sepsis CT: contained rupture Innominate a. aneurysm RCCA cutdown

48 12 Fr sheath 13 x 50 Viabahn 12 mm balloon 6 weeks IV Abx One year oral suppression

49 BP discrepancy 40 mm Hg (L>R) Asymptomatic Followup: 7 years

50 60 y.o. female smoker R retinal infarct x 2

51 Therapy for single-vessel disease Takach JVS 2005;42: patients: operation 162 patients: PTA + stent At 5 years, freedom from failure: 93% for the operative group 84% for the endovascular group

52 BRACHIOCEPHALIC PTA / STENT CONTRAINDICATIONS Extreme tortuosity Lesion adjacent to an aneurysm Presence of fresh thrombus Lesions which extend to the origin of the vertebral artery / CCA

53 1. Smoking / COPD Predictors of restenosis 2. Age 3. Vessel diameter <7 mm 4. Stent longer than 40 mm 5. Stent fracture 6.?? PTA vs stent Mousa et al J Vasc Surg 2015;62:106. Karpenko et al J Stroke Cerebrovasc Dis 2017;26:87 Usman et al J Vasc Interv Radiol 2010;21:1364 Van de Weijer et al Eur J VES 2015;50:13

54 Innominate PTA / stent - (Ward)

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56 Nitinol stent

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59 SVS Practice Guidelines TEVAR 1. Elective TEVAR: routine preop revascularization if LSCA needs to be covered for proximal seal 2. Revascularize in select patients who have anatomy the compromises perfusion to critical organs (eg, LIMA- LAD) 3. Urgent TEVAR: individualize treatment

60 CONCLUSIONS Endovascular is a reasonable initial treatment option especially for focal disease Do not preclude subsequent operation Indications are the same as for surgical intervention In general, not as durable as surgical alternatives Beware of combined CCA PTA / stent and CEA Covered stents for trauma, embolic lesions Open surgical skills remain valuable