Endovascular treatment of innominate artery stenosis via the bilateral brachial approach

Abstract

Endovascular treatment (stenting) has evolved as an effective and safe treatment modality for symptomatic subclavian and innominate artery disease. Most of these patients have comorbid conditions associated with atherosclerotic vascular disease, which is responsible for the access site and increased difficulty of procedure. We report a case of symptomatic innominate artery stenosis with concomitant atherosclerotic disease of the abdominal aorta successfully treated with using coronary devices and the pull-through technique via the bilateral brachial approach.

1 Introduction

Innominate artery stenosis is commonly caused by atherosclerosis and results in vertebrobasilar insufficiency, upper extremity claudication, and cerebral embolism. Concomitant coronary artery disease is present in 28–79% of the patients with subclavian or innominate artery disease, peripheral artery disease is present in 43–51% of the patients, and carotid artery disease is present in 29–49% of the patients . These figures reflect the extent and severity of atherosclerotic vascular disease. Endovascular treatment for symptomatic subclavian and innominate artery disease has a similar success rate to open surgery with less morbidity and mortality . However, there is little experience with endovascular treatment of innominate artery stenosis via the bilateral brachial approach in patients who have concomitant atherosclerotic disease of the abdominal aorta. Here we present a patient with symptomatic innominate artery stenosis in whom endovascular treatment was done successfully via the bilateral brachial approach using coronary devices and the pull-through technique.

2 Case report

A 57-year-old man presented with a 2-month history of right-sided amaurosis fugax and light headedness. His cardiovascular risk factors included diabetes mellitus with mild nephropathy, hypertension, dyslipidemia, prior myocardial infarction, and smoking. On examination, the right upper limb pulses were weak, and there was a 30-mmHg pressure difference between the two upper extremities. Duplex ultrasound showed an increase of the peak systolic velocity to 466 cm/s in the innominate artery and permanently reversed flow in the right vertebral artery. Contrast-enhanced magnetic resonance angiography revealed proximal innominate artery stenosis and brain magnetic resonance imaging (MRI) showed an old lacunar infarct in the right parietal lobe. Furthermore, contrast-enhanced computed tomography and ultrasound revealed severe atherosclerotic plaque with mobile components in the infrarenal abdominal aorta and bilateral femoral artery stenosis. Treatment options, including endovascular and surgical procedures, were presented to the patient. Surgical techniques for innominate artery lesions include direct reconstruction and extra-anatomic bypass, but bypass was not advocated because of the low patency rate, interference with future coronary artery bypass grafting, and chronic risk of embolization. The patient selected endovascular treatment.

A 7.2-Fr, 35-cm-long sheath (Zeon Medical, Tokyo, Japan) and an 8.2-Fr, 11-cm-short sheath (Medikit, Tokyo, Japan) were introduced into the right brachial artery and left brachial artery, respectively. Heparin was administered to maintain an activated clotting time ≥250 s. Bidirectional angiography via the right subclavian artery and thoracic aorta demonstrated 90% stenosis of the proximal innominate artery with severe tortuosity ( Fig. 1 A and B). Anterograde flow in the right common carotid artery and retrograde flow in the right vertebral artery were confirmed at the same time, and a pressure gradient of 84 mmHg across the stenosis was detected. A PercuSurge GuardWire (balloon diameter 3–6 mm) (Medtronic, Minneapolis, MN, USA) cerebral protection device was placed in the right internal carotid artery from the long right brachial artery sheath using a 6-Fr femoral right 3.5 mach1 (Boston Scientific, Natick, MA, USA) guide catheter for support ( Fig. 2 ). An 8-Fr multipurpose mach1 (Boston Scientific) guide catheter was tried first from the left brachial artery sheath, but it did not fit the ostium of the innominate artery. Exchange for an 8-Fr renal double-curve mach1 (RDC) (Boston Scientific) guide catheter overcame this problem. Then the innominate artery stenosis was crossed with a 0.014-in. Suoh (Asahi Intecc, Aichi, Japan) coronary guide wire through the 8-Fr RDC guide catheter with minimal difficulty ( Fig. 3 ). The pull-through technique was performed ( Fig. 4 ); an Amplatz goose neck snare (loop diameter 10 mm) (eV3, Plymouth, MN, USA) was inserted into the long right brachial artery sheath to catch the 0.014-in. Suoh coronary guide wire, which was subsequently drawn out through the long right brachial sheath. After the stenosis was successfully crossed from the long right brachial artery sheath, an 8.0×17 mm Express LD stent (Boston Scientific) was deployed at 10 atmospheres through the 8-Fr RDC guide catheter via the left brachial artery sheath under cerebral embolic protection ( Fig. 5 A and B). After stenting, a 6-Fr Export (Medtronic) aspiration catheter was inserted into the right internal carotid artery via the long right brachial artery sheath, and aspiration of atheromatous debris was performed in this vessel as well as in the long right brachial artery sheath ( Fig. 5 C). Good antegrade flow was achieved, and there was complete disappearance of the pressure gradient. The final result is shown in Fig. 6 . There were no procedural complications. The patient was prescribed clopidogrel for 3 months and aspirin indefinitely. At follow-up after 6 months, the patient was symptom-free and duplex ultrasound demonstrated good antegrade flow in the right common carotid artery and vertebral artery.