SCAI Fall Fellows Course 2012 Subclavian/Innominate Case Presentation Daniel J. McCormick DO, FACC, FSCAI Director, Cardiovascular Interventional Therapy Pennsylvania Hospital University of Pennsylvania Helath System
DISCLOSURES Educational Grants: Cordis, Boston Scientific, Abbott Vascular, St. Jude, Research Grants: Cordis, Boston Scientific, Gore, St. Jude, Abbott Vascular
CASE 57 yo man, suffered syncopal episode while removing packages from his car PMH: DM, Htn, Dyslipidemia, SH: former heavy tobacco usage, works as janitor ROS: +R. arm fatigue with activity, occasional transient episodes of dizziness; Negative history of arrhythymia
CASE Continued PE: L arm with 40 mm Hg greater than right arm Cardiac exam unremarkable Vascular: Diminished R. carotid pulse c/w left Referred for Vascular Duplex Study
Carotid C Duplex
Carotid Duplex Mild plaque in the R. CCA/ICA with diminished flow R. ECA with reversal of flow R. Vertebral/Subclavian with retrograde flow L. ICA with mild stenosis L. vertebral artery with antegrade flow Summary: Features consistent with subclavian steal
MRI Angiography of Neck Patent but diffusely smaller R. CCA Moderate stenosis of R. innominate artery suspected Normal caliber and flow in L. CC/IC arteries Normal flow in L. vertebral and reversal of flow in R. vertebral artery
Arch Angiogram 95% Innominate Stenosis
Ostial Innominate Angiogram
Left Common Carotid Angio
Left Vertebral Angiogram
Diagnostic Angiography Type I Aortic Arch Innominate artery with 90% lesion at ostium R. vertebral artery not visualized on innominate angiography Mild disease of L. carotid system L->R crossover on intracerebral angiography Collateralization of R. hemisphere from L. external carotid L. vertebral angiography fills R. vertebral via patent Circle of Willis
Innominate Angio w 9fr JR4 Guide
Double.014 Guidewires- Nav6 EPD advanced to LICA
NAV6 EPD Deployment RICA
6 x 20 Viatrac Balloon over 2 0.14 Guidewires
Post PTA Result
10 x 29 Omnilink Stent
Stent Deployment
Post-Stent w EPD in RICA
Final Angiogram Right Innominate Ostial Stent
Endovascular Intervention Pre-close with 9 F sheath 9 F JR4 guide Nav6 0.14 EPR wire in R. ICA, Spartacore 0.14 in R. axillary NAV6 filter in R.ICA 6 x 20 mm Viatrac balloon angioplasty 10 x 29 Omnilink BES deployed over 2 wires Subsequent visualization of R. vertebral artery Successful Innominate Stenting with EPD and 2-wire technique
Post-Procedure Patient doing well over 3 months out from stenting No further syncope, arm claudication Upper extremity blood pressures essentially equal Carotid duplex U/S: Antegrade R. vertebral flow
Clinical Manifestations Arm claudication, hand or finger pain Paresthesias, Raynaud s phenomenon Ischemic Neurologic Syndromes Vertebral-subclavian steal vertigo, syncope, ataxia, diplopia, motor deficits Coronary-subclavian steal angina, infarction
Diagnosis Diagnosis of the lesion Clinically: Blood pressure difference >20 mmhg (Segmental blood pressures) Duplex scan M.R.I. OR M.R.A. CTA Scan ARTERIOGRAPHY REMAINS THE GOLD STANDARD
Surgery vs. Endovascular Approach Carotid-subclavian bypass Stent 70% stenosis 35mm Grad 100% left subclavian
Endovascular Therapy Approach Femoral approach: Larger catheters or sheaths could be used Easy for stenotic lesions Difficult for occlusions and ostial lesions Brachial approach: Difficult upstream visualization Best for occlusions Useful after failure of femoral approach Combined Femoral/Brachial approach for occlusions with pull through wire snare technique ( Body Floss )
Endovascular Therapy Basic Equipment Selection of equipment depends on lesion anatomy and approach Guiding catheters 8F Multipurpose Judkins right OR Introducer sheaths 6-7F / 60-90cm - PREFERRED Guide wires: 0.035 Hydrophilic 0.035 Super stiff amplatz/ Magic Torque 0.014 Coronary wires, only when using EPD
Innominate Subclavian PTA / Stenting Pre-vertebral Location/ostial lesion: Balloon expandable stents Greater radial force More accurate placement Avoid covering vertebral artery and IMA Stent should protrude into aorta by 1-2 mm Select at least >= 20 mm long stents Deflate balloon/stents balloon slowly Avoid matching stent size to the post-stenotic dilatation Mild residual stenosis is acceptable
AVOID EXCESSIVE CATHETER MANIPULATION
MRI Brain w/o contrast
Complications Distal embolic events Brachial artery thrombosis Reperfusion arm edema + compartment syndrome Stroke (infarct or hemorrhage) Restenosis and stent fracture Access complications (pseudoaneurysm, hematoma)
Technical Considerations: Lesions to Avoid Extreme tortuosity Lesion adjacent to an aneurysm Presence of fresh thrombus Long total occlusion with extensive calcification
Take Home Points Indications for RX: VBI, Carotid steal syndrome, UE ischemia, Digital emboli Need for EPD remains undetermined, rarely reported in the literature 2 wire technique can be useful in subclavian/innominate intervention and allows Internal Carotid EPD
Learning Curve
Anatomy
Take Home Points Atherosclerotic occlusive disease involving aortic arch branches common in patients older than 65 Innominate artery stenosis (IAS) is uncommon However, assoicated with significant morbidity Important cause of symptomatic extracranial cerebrovascular disease IAS natural history not well known
Take Home Points Most common etiologies in US: atherosclerosis and Takayasu s arteritis Symptoms: Arm claudication, paresthesias, weakness Vertigo, syncope, transient quadriparesis Surgical revascularization was the historical standard but it requires median sternotomy and is associated with significant morbidity and mortality (10%) 1 Endovascular intervention has become considered optimal first-line therapy 1 Ryer et al. J Endovasc Ther 2010