angioplasty and stenting of the great vessels j. bayne selby, jr., md medical university of south...
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Angioplasty and Stenting Angioplasty and Stenting of the Great Vesselsof the Great Vessels
J. Bayne Selby, Jr., MDJ. Bayne Selby, Jr., MD
Medical University of South Medical University of South CarolinaCarolina
Institut fur Diagnostische und Interventionelle RadiologieUniversitat Frankfurt am Main
June 7, 2006
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HistoryHistory
1964 First angioplasty report by Dotter 1964 First angioplasty report by Dotter and Judkinsand Judkins
1980 First subclavian angioplasty report 1980 First subclavian angioplasty report by Bachman and Kimby Bachman and Kim
1991 Report by Soulen for subclavian 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary angioplasty proximal to LIMA coronary bypass graftbypass graft
1993 First subclavian stent use reported 1993 First subclavian stent use reported by Mathiasby Mathias
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OverviewOverview
Stenoses/occlusion in the great Stenoses/occlusion in the great vessels usually represent difficult vessels usually represent difficult areas to access surgicallyareas to access surgically
Results with angioplasty have been Results with angioplasty have been uniformly good in stenosesuniformly good in stenoses
Use of stents has resulted in similar Use of stents has resulted in similar results for complete occlusionsresults for complete occlusions
Role of distal embolic protection Role of distal embolic protection devices unclear at this timedevices unclear at this time
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95% Left Subclavian 95% Left Subclavian StenosisStenosis
Pre Post Post Aortagram
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Left Subclavian Stenosis – Pre, Left Subclavian Stenosis – Pre, Post, and 6 month follow-upPost, and 6 month follow-up
Pre Immediate Post 6 months post
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Patient SelectionPatient Selection
As always, treatment should only be As always, treatment should only be performed in those patients who performed in those patients who have both a hemodynamically have both a hemodynamically significant lesion and appropriate significant lesion and appropriate corresponding symptomscorresponding symptoms
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Anatomic LocationsAnatomic Locations
Left Subclavian (most common)Left Subclavian (most common) BrachiocephalicBrachiocephalic Left Common Carotid OriginLeft Common Carotid Origin Right Subclavian (often in aberrant Right Subclavian (often in aberrant
vessel)vessel)
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IndicationsIndications
Upper Extremity IschemiaUpper Extremity Ischemia Arm ClaudicationArm Claudication Emboli from lesion to handEmboli from lesion to hand
Cerebral IschemiaCerebral Ischemia Anterior (carotid) symptomsAnterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian Vertebro-basilar Insufficiency w/wo subclavian
stealsteal Diminished Inflow to GraftDiminished Inflow to Graft
Angina in patient with LIMAAngina in patient with LIMA Claudication in patient with Ax-femClaudication in patient with Ax-fem
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DiagnosisDiagnosis
Clinical HistoryClinical History BLOOD PRESSURES in both arms – BLOOD PRESSURES in both arms –
simplesimple MRAMRA CTACTA Conventional Angiography – AP and Conventional Angiography – AP and
LAOLAO
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Diagnostic AngiographyDiagnostic Angiography
Evaluate for central lesion Evaluate for central lesion (stenosis/occlusion)(stenosis/occlusion)
Evaluate for evidence of distal emboli Evaluate for evidence of distal emboli (then do echocardiography of heart)(then do echocardiography of heart)
Evaluate for vasospastic disorder, e.g., Evaluate for vasospastic disorder, e.g., Raynaud’s (do angio before and after Raynaud’s (do angio before and after vasodilator)vasodilator)
Evaluate for thoracic outlet syndrome (do Evaluate for thoracic outlet syndrome (do abduction and adduction angio)abduction and adduction angio)
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Great Vessel Angioplasty/Stent Great Vessel Angioplasty/Stent TechniqueTechnique
Do baseline neurological examDo baseline neurological exam Initial high quality diagnostic thoracic Initial high quality diagnostic thoracic
aortagramaortagram Arteriography of distal vascular beds as Arteriography of distal vascular beds as
allowed by degree of diseaseallowed by degree of disease First attempt to cross lesion from belowFirst attempt to cross lesion from below Use brachial approach if necessaryUse brachial approach if necessary Give Heparin once lesion has been crossed Give Heparin once lesion has been crossed
(2,000-3,000 units)(2,000-3,000 units)
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Great Vessel Angioplasty/Stent Great Vessel Angioplasty/Stent TechniqueTechnique
Have nurse perform neurological tests on patients Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, at regular intervals (e.g., speak, grip strength, smile, wiggle toes)smile, wiggle toes)
Use guiding catheter or sheathUse guiding catheter or sheath Try to use appropriate ballon size for initial Try to use appropriate ballon size for initial
dilatation, but pre-dilate if lesion is too tight to get dilatation, but pre-dilate if lesion is too tight to get acrossacross
Leave balloon up for 10 secondsLeave balloon up for 10 seconds Stent for >30% residual stenosis, dissection, recoilStent for >30% residual stenosis, dissection, recoil Consider primary stent based on appearance of Consider primary stent based on appearance of
lesionlesion
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Brachiocephalic (Innominate) Brachiocephalic (Innominate) Artery AngioplastyArtery Angioplasty
99% stenosis at originof brachiocephalic artery
Cross lesion from an axillary approach
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Brachiocephalic (Innominate) Brachiocephalic (Innominate) Artery AngioplastyArtery Angioplasty
10 mm balloon with “waist” 10 mm balloon fully inflated
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Brachiocephalic (Innominate) Brachiocephalic (Innominate) Artery AngioplastyArtery Angioplasty
Initial 99% stenosis Final with residual stenosis <30%Note post stenotic dilatation
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Subclavian Stenosis proximal Subclavian Stenosis proximal to LIMA coronary graft – no to LIMA coronary graft – no
stentstent
Diffuse stenosis – poor fillingof the LIMA graft
S/P Angioplasty – circa 1991
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Stenosis in Single supra-aortic Stenosis in Single supra-aortic Vessel – Now What?Vessel – Now What?
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Follow up – MR? CT? Angio?Follow up – MR? CT? Angio?
Peloschek P., et al. The Role of Multi-Peloschek P., et al. The Role of Multi-slice Spiral CT Angiography in Patient slice Spiral CT Angiography in Patient Management After Endovascular Management After Endovascular Therapy. Cardiovascular and Therapy. Cardiovascular and Interventional Radiology, In PressInterventional Radiology, In Press
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Subclavian Stenosis proximal Subclavian Stenosis proximal to LIMA coronary graft – with to LIMA coronary graft – with
stentstent
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Stenosis within stentStenosis within stent
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Bifurcation LesionsBifurcation Lesions
Can occur at right subclavian – right Can occur at right subclavian – right common carotid bifurcationcommon carotid bifurcation
Must use RAO projection to evaluate Must use RAO projection to evaluate stenosisstenosis
Options include: Options include: 1) simple angioplasty1) simple angioplasty 2) kissing balloon angioplasty2) kissing balloon angioplasty 3) simple stent3) simple stent 4) kissing stents4) kissing stents
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Bifurcation LesionsBifurcation Lesions
Subclavian Steal95% stenosis in proximalright subclavian artery
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Bifurcation LesionsBifurcation Lesions
Kissing balloon from femoral andright axillary approach
Final ResultExcellent is the Enemy of Good!
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Bifurcation LesionBifurcation LesionPulse Volume RecordingsPulse Volume Recordings
Right Arm Left Arm
Fingers of Right Hand
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Life Table AnalysisLife Table Analysis30 Subclavian Angioplasty Patients 30 Subclavian Angioplasty Patients
University of VirginiaUniversity of Virginia
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Summary of Largest Series of PTA of Summary of Largest Series of PTA of Brachiocephalic Arterial StenosesBrachiocephalic Arterial Stenoses
AuthorsAuthors No. of LesionsNo. of Lesions Technical Technical SuccessSuccess
Clinical Clinical SuccessSuccess
ComplicationComplications – s – NeurologicNeurologic
ComplicationComplications - Others - Other
Months Months Follow-up Follow-up (mean)(mean)
Selby et alSelby et al 3232 32/32 (100%)32/32 (100%) 31/32 (97%)31/32 (97%) 00 22 4-88 (36)4-88 (36)
Kachel et alKachel et al 4747 47/47 (100%)47/47 (100%) 45/47 (96%)45/47 (96%) 00 22 3-109 (58)3-109 (58)
Hebrang et alHebrang et al 4343 40/43 (93%)40/43 (93%) 34/43 (79%)34/43 (79%) 00 00 6-48 (29)6-48 (29)
Dorros et alDorros et al 2222 22/22 (100%)22/22 (100%) 21/22 (95%)21/22 (95%) 00 22 2-73 (28)2-73 (28)
Motarjeme et Motarjeme et alal
1616 16/16 (100%)16/16 (100%) 16/16 (100%)16/16 (100%) 00 00 8-60 (27)8-60 (27)
Vitek et alVitek et al 3535 35/35 (100%)35/35 (100%) -- 00 00 --
Burke et alBurke et al 2929 26/29 (90%)26/29 (90%) -- 11 11 (37)(37)
Insall et alInsall et al 3434 34/34 (100%)34/34 (100%) 30/34 (89%)30/34 (89%) 11 22 2-90 (26)2-90 (26)
Romanowshi Romanowshi et alet al
2525 23/25 (92%)23/25 (92%) 17/25 (68%)17/25 (68%) 00 00 8-111 (50)8-111 (50)
Erbstein et alErbstein et al 2121 18/21 (86%)18/21 (86%) 17/21 (81%)17/21 (81%) -- -- 18-2618-26
Millaire et alMillaire et al 4646 45/46 (98%)45/46 (98%) 37/44 (84%)37/44 (84%) 11 44 9-101 (41)9-101 (41)
Wilms et alWilms et al 2323 21/23 (91%)21/23 (91%) 18/21 (86%)18/21 (86%) 11 22 6-60 (25)6-60 (25)
Farina et alFarina et al 2323 21/23 (91%)21/23 (91%) (54%)(54%) -- 11 (30)(30)
OVERALLOVERALL 396396 380/396 380/396 (96%)(96%)
239/305 239/305 (78%)(78%)
44 1616 --
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Summary of Series of Brachiocephalic Summary of Series of Brachiocephalic Arterial OcclusionsArterial Occlusions
AuthorsAuthors No. of OcclusionsNo. of Occlusions Technical SuccessTechnical Success Clinical SuccessClinical Success No. of Patients No. of Patients Receiving StentsReceiving Stents
Kachel et alKachel et al 77 1/7 (15%)1/7 (15%) -- 00
Hebrang et alHebrang et al 99 5/9 (56%)5/9 (56%) -- 00
Dorros et alDorros et al 1111 11/11 (100%)11/11 (100%) -- 00
Motarjeme et alMotarjeme et al 77 1/7 (15%)1/7 (15%) 1/1 (100%)1/1 (100%) 00
Mathias et alMathias et al 4646 38/46 (83%)38/46 (83%) 32/38 (84%)32/38 (84%) 77
Duber et alDuber et al 88 7/8 (88%)7/8 (88%) 3/7 (43%)3/7 (43%) 77
BatesBates 55 5/5 (100/5)5/5 (100/5) -- 55
OverallOverall 9393 68/93 (73%)68/93 (73%) 36/46 (78%)36/46 (78%) 1919
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ComplicationsComplications
Puncture site complications, femoral Puncture site complications, femoral or brachialor brachial
Rupture of vesselRupture of vessel Emboli from angioplasty siteEmboli from angioplasty site Stent misplacementStent misplacement
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ComplicationsComplications
Mathias, et al: 38 patients with total Mathias, et al: 38 patients with total occlusions – No significant embolic occlusions – No significant embolic occlusionsocclusions
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ComplicationsComplications
Literature review by Kachel, et al: Literature review by Kachel, et al: 774 supraaortic lesions treated with 774 supraaortic lesions treated with PTAPTA 0.5% Major complications0.5% Major complications 3.5% Minor complications3.5% Minor complications
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ExplanationsExplanations
20 second delay in restoration of 20 second delay in restoration of antegrade flow in vertebral artery antegrade flow in vertebral artery following angioplasty – Ringelstein, et al, following angioplasty – Ringelstein, et al, Nuclear Medicine dataNuclear Medicine data
Lack of clinical significance of small emboli Lack of clinical significance of small emboli to handto hand
Possible different response of large vessels Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli to angioplasty/stent (iliac vs. SFA emboli experience)experience)
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Still, now we have protection Still, now we have protection devices …devices …
Landing zone for protection device in Landing zone for protection device in supra-aortic angioplasty is often supra-aortic angioplasty is often vessel too largevessel too large
Probably should use it when possibleProbably should use it when possible
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We’re not done yet!We’re not done yet!Articles to be published in Articles to be published in
20062006 6 articles on results of simple 6 articles on results of simple
angioplasty and/or stenting of great angioplasty and/or stenting of great vesselsvessels
3 articles on great vessel disease 3 articles on great vessel disease treatment in conjunction with treatment in conjunction with thoracic aortic stent graftthoracic aortic stent graft
2 articles on percutaneous treatment 2 articles on percutaneous treatment for arteritisfor arteritis
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ConclusionConclusion
Angioplasty, with or without stenting is Angioplasty, with or without stenting is highly effective for stenoses of the great highly effective for stenoses of the great vesselsvessels
Occlusive disease in the great vessels Occlusive disease in the great vessels should always be treated with stentshould always be treated with stent
Long term result are excellent (70-90%), Long term result are excellent (70-90%), but follow –up with CTA upon return of but follow –up with CTA upon return of symptoms may be necessarysymptoms may be necessary
Consider the use of distal embolic Consider the use of distal embolic protection, although rate of complications protection, although rate of complications has been low without ithas been low without it
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SummarySummary
Angioplasty of the Great Vessels can be a Angioplasty of the Great Vessels can be a useful treatment in a surgically difficult areauseful treatment in a surgically difficult area
Results mimic those of the common iliac Results mimic those of the common iliac arteries (>90% success) and have further arteries (>90% success) and have further improved with the use of stents, particularly improved with the use of stents, particularly for occlusionsfor occlusions
Improvements in technology have increased Improvements in technology have increased the technical success in occlusionsthe technical success in occlusions
Complications are low, but remain a hazard – Complications are low, but remain a hazard – consideration should be given to the use of consideration should be given to the use of distal protection devices when anatomy is distal protection devices when anatomy is suitablesuitable