Subclavian Revascularization. Douglas E. Drachman, MD, FSCAI Division of Cardiology Vascular Medicine Section December 9, 2014

Transcription

1 Subclavian Revascularization Douglas E. Drachman, MD, FSCAI Division of Cardiology Vascular Medicine Section December 9, 2014

2 Disclosure Information Douglas E. Drachman, MD, FACC Abbott Vascular, Inc.: Advisory Board Atrium Medical Corporation: Research Grant Support idev Technologies, Inc.: Research Grant Support Lutonix/BARD: Research Grant Support Off-label use of products will be discussed in this presentation as indicated. Many stents used in the peripherial arterial circulation are indicated for biliary or tracheal application.

3 Three Main Objectives: Subclavian stenosis marker of systemic athero Arch anatomy, lesion etiology and morphology, drive the clinical response Interventional strategies and pitfalls

4 The vital prognosis of subclavian stenosis Aboyans V, et al. J Am Coll Cardiol 2007; 49:

5 The Aortic Arch: 31 Flavors: anomalous anatomy The anatomy drives the pathophysiology 20-30% 7% A classic example Uflacker, Renan, ed. Atlas of Vascular Anatomy. Philadelphia: Lippincott, Williams & Wilkins, 2007/

6 Subclavian Steal Defined: >20mmHg brachial BP discrepancy Duplex ratio 5.5 in-stenosis ( > 75% stenosis) Ipsilateral vertebral flow Reversal Bidirectional Normal BP cuff x 5 min: duplex vert when cuff let down CTA, MRA, or Angio LAO to show LSCA RAO caudal to show RSCA

7 Subclavian Steal Surgical treatment Carotid-subclavian bypass Carotid-axillary bypass Aorto-axillary bypass Long term patency > 90%; low morbidity/mortality

8 Subclavian Steal Endovascular treatment Convention: femoral access ( brachial, radial) 90cm sheath (6F or 7F) Balloon expandable stent, unless distal SCA No EPD Technical success: 90%, 50-60% if CTO MACCE 2% 90% patent at 1 year 80-90% secondary patency at 5 years

9 Subclavian Steal

10 Wiring the CTO (avoiding the L vert)

11 Transition sheath, PTA/stent

12 Transition sheath, PTA/stent

13 Another LSCA Stenosis: Transradial Approach Prior dx angiography 5F Raabe from L radial

14 LSCA Steal: Anatomy Drives Physiology 65 yo F with HTN, dyslipidemia, known CAD (s/p MI and CABG 4 yrs prior) Multiple subsequent presentations with CP and CHF; ETT negative 3 yrs prior One week of crescendo angina Bedside CK isoenzyme and troponin-i neg

15 Coronary angiography:

16 Coronary DSA:

17 Arch aortography:

18 Return for brachial access:

19 PTA, then stent:

20 Result: restoration of antegrade flow Uneventful postprocedural course Home day 1 post stent

21 Bulky, Exophytic Left Subclavian Lesion

22 We elected to use EPD in the vertebral

23 Intervention, Result debris captured!

24 RSCA stenosis: Another EPD Opportunity Absent Vertebral Flow

25 What approach? Just stent it! Embolic protection? Simultaneous retrograde access? Surgery?

26 Our decision: Ad hoc review with Surgery PTA Bilateral groin access 5F Raabe to RCCA for EPD 6F Pinnacle to innominate for PTA

27 Baseline intracerebral angiography

28 Recalcitrant to PTA 6 x 20mm PTA

29 What now? Declare victory More PTA? Stent?

30 We stented it 7 x 23mm BES Stick the landing proximally Intentional distal overhang

31 A waist with deployment jaw and chest pain with post-dilatation (8mm)

32 Final angio

33 Epilogue Embolic protection device constrained, removed Macroscopic debris noted in filter Patient reported, I don t feel right Non-focal neurologic evaluation

34 Post-intervention cerebral angio

35 Post-intervention cerebral angio

36 Medical management Observation in Neuro ICU Systemic anticoagulation, DAPT Permissive HTN for cerebral perfusion No noteworthy or residual neurologic deficit

37 68 yo woman with subclavian steal syndrome (Don t try this at home )

38 Don t try this at home

39 Self-expanding stent

40 Re-look 2 months post-stenting

41 Conclusions: Subclavian Revasc Variable anatomy, location of lesion influences clinical syndrome Treatment determined by location and by underlying etiology Endovascular rx may be effective in many lesion types Plan approach, meticulous technique to minimize complications

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