Abstract
Subclavian artery stenosis is associated with increased cardiovascular disease mortality. It remains an important treatable cause of upper extremity, brain and cardiac ischemia. Endovascular treatment with angioplasty and stenting has become the preferred modality of treatment. Surgical revascularization is reserved for difficult cases with unfavorable anatomy to endovascular approach. Here we describe a case of subclavian artery stenosis causing subclavian steal syndrome with unfavorable anatomy to stenting treated successfully with drug coated balloon angioplasty with maintenance of patency at 6 months.
Highlights
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A case of subclavian artery stenosis causing subclavian steal syndrome
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Subclavian artery stenosis treated successfully with drug coated balloon angioplasty
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Drug coated balloon angioplasty is a reasonable alternative to stenting when anatomy is unfavorable.
1
Introduction
Subclavian artery stenosis (SAS) is present in approximately 2% in the general population and 7% in patients with risk factors for atherosclerotic disease . Atherosclerosis is by far the most common cause of this condition, however, other unusual etiologies include arteritis, radiation induced inflammation, compression syndromes, fibromuscular dysplasia, and neurofibromatosis . The left subclavian artery is four times more likely to be affected than the right or innominate arteries.
Most patients with SAS are asymptomatic . Subclavian artery occlusive disease is often found incidentally by noting a blood pressure discrepancy between arm pressures or on ultrasound testing of patients with carotid or coronary artery disease . Other clinical manifestations include upper extremity ischemic symptoms with arm claudication related to exercise or embolization to the digits . Subclavian steal syndrome occurs as a result of flow reversal in the vertebral artery, leading to symptoms of vertebrobasilar insufficiency .
Although no randomized trials are available, retrospective studies suggest that percutaneous transluminal angioplasty and stenting of SAS are safe in patients with appropriate anatomy . In general, surgical revascularization is preferred in patients with unfavorable anatomy for intervention or if percutaneous treatment will jeopardize the integrity of the adjacent major arteries. The role of drug coated balloon angioplasty in SAS treatment is unknown. We present a case of SAS, with challenging anatomy for stenting, that was treated successfully with drug coated balloon angioplasty.
2
Case history
The patient is a 68-year-old woman, who presented to our clinic with symptoms of right arm claudication and weakness with minimal arm activity. She had multiple episodes of unexplained dizziness, vertigo and syncope. Her past medical history was significant for essential hypertension, hyperlipidemia and type II diabetes mellitus. On physical exam, her systolic blood pressure was 30 mm Hg greater in the left arm compared to the right arm. Radial and ulnar pulses were not palpable in the right upper extremity. Her neurological exam was unremarkable. Pulse-wave Doppler study of the right vertebral artery showed retrograde flow suggestive of right subclavian steal syndrome ( Fig. 1 ). Right upper extremity angiography performed through right radial access demonstrated high-grade SAS adjacent to the ostia of both the vertebral and carotid arteries.
The patient was taken back to the catheterization lab for percutaneous intervention of the Right Subclavian Artery. A 6 Fr 25 cm Glidesheath was inserted into the right radial artery. An 8 Fr 90 cm long sheath was inserted into the right femoral artery. Intravenous unfractionated heparin was employed as an anticoagulant during the procedure maintaining an activated clotting time of 250–300 s. The subclavian stenosis was crossed in a retrograde approach using a 0.035″ stiff angled Glidewire (Terumo) with support from a 125 cm angled 4 Fr Glidecatheter (Terumo). Once in the aorta, the distal end of the wire was captured with a 6 Fr 15 mm Gooseneck Snare (Medtronic) and externalized from the right femoral sheath. The glide wire was exchanged for an 0.035″ Amplatz Super-Stiff wire (Boston Scientific) which allowed delivery of the antegrade sheath into the innominate artery. The lesion was pre-dilated up to a 7.0 mm diameter angioplasty balloon. Tortuous anatomy and proximity to the right vertebral and carotid arteries made stenting with either a balloon expandable or self-expanding stent challenging. Instead of stenting, the lesion was then treated with a 7 × 40 mm IN.PACT Admiral paclitaxel drug coated balloon (Medtronic). Final angiography was performed revealing 0% residual stenosis, elimination of the gradient, and restoration of antegrade flow in the right vertebral.
Six months later, bilateral lower extremity angiography was performed for evaluation of claudication. A right upper extremity angiogram was also done and demonstrated widely patent right subclavian artery with no pressure gradient ( Fig. 2 ).
