Tyrone J. Collins Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA Revascularization of supra‐aortic arterial disease (complicated peripheral artery disease) is usually elective and prophylactic to prevent initial or recurrent ischemic events. Surgical revascularization was once considered the treatment of choice [1]. Successful reports of percutaneous transluminal angioplasty (PTA) and stenting introduced endovascular treatment as an equal or possibly better than surgery option [2]. Each patient is unique, and the risk is multifactorial with both demographic and anatomic risk factors. Several “high‐risk” features are generally considered when treating carotid artery disease in these patients [3] (Table 1.1). Some of these features are also risk factors for innominate intervention. The level of stenosis and/or occlusion, vessel tortuosity, amount of calcification, presence or absence of thrombus, concomitant vascular abnormalities, and comorbid conditions will also affect the risk with revascularization of the other supra‐aortic vessels. Although some authors may consider endovascular therapy the treatment of choice for innominate atherosclerotic disease, surgical therapy has been shown to be safe and effective [4]. During a period of almost 20 years from 1974 to 1993, Kieffer et al. revascularized surgically 148 patients with acceptable rates of complications, late mortality, long‐term patency, freedom from neurologic events, and reoperation [4]. Table 1.1 High‐risk features reported in the literature. Step 1. Identification of the level of stenosis is the initial step. Computed tomography angiography (CTA) can be useful prior to an invasive procedure. This can allow for planning the interventional strategy and considering alternative forms of treatment. Additionally, CTA can be used to size the reference vessels. When considering the choice of arterial access remember that catheter size is limited with radial access and the need to cross the stenosis is usually necessary from the radial or brachial approach. If intervention is planned, injections are against the direction of blood flow when working from the arm approach. I prefer the femoral approach to innominate stenoses. Invasive angiography can be done with digital and/or subtraction angiography. A pigtail catheter is positioned in the ascending aorta proximal to the origin of the innominate artery. The angiography is performed in the 30° left anterior oblique (LAO) projection. Selective angiography is done with a Judkins right diagnostic catheter or guiding catheter (Figure 1.1a,b). Other diagnostic catheters can be used for selective angiography. The “working view” is the angulation that allows for delineation of the stenosis, any adjacent branches, and the ostium of the innominate. Road mapping may be useful but also take advantage of any vascular calcification as a point of reference. Step 2. After the decision to intervene and baseline angiography has been performed, the innominate is engaged with an 8 Fr guide catheter. A different approach is to use a diagnostic catheter to engage the innominate artery, cross the stenosis with the appropriate wire, and introduce a 6 Fr sheath over the wire to the ostium of the innominate. Anticoagulation to achieve an activated clotting time (ACT) > 250 s is administered. Depending on the available balloons and stents, the appropriate wire (0.014–0.035 in.) is steered across the stenosis. The tip of the wire is passed into the subclavian artery. Wire tip can also be placed in the common or external carotid artery. Innominate artery PTA and stenting is usually performed without utilizing a distal embolic protection device (EPD). If you choose to use EPD, the necessary wire or filter can be positioned in the internal carotid artery. Horesh reported a case of innominate stenting with a covered stent and distal protection [5]. He emphasized the need to individualize patients and consider using embolic protection in high‐risk patients. Hybrid procedures have been performed using balloon occlusion to trap embolic debris. Figure 1.1 (a) Heavily calcified aorta and supra‐aortic vessels. (b) Baseline innominate artery selective angiogram. Step 3. Predilatation with a balloon is performed. The initial balloon is usually undersized but gives an idea of the ability to distend the lesion (Figure 1.2). The Shockwave Lithoplasty System (Medical Inc.) has been used to successfully treat severely calcified innominate stenosis prior to stenting [6]. This system has also been used in a hybrid operation [7]
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Innominate & Carotid Artery Intervention in High‐Risk Patients
Introduction
Innominate Interventions in High‐Risk Patients
Catheter‐based Therapy for An Innominate (Brachiocephalic) Stenosis
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