1

Introduction

Subclavian stenosis or occlusive disease presents in various ways including cerebrovascular insufficiency, upper extremity ischemia and myocardial ischemia (coronary subclavian steal syndrome). Patients may complain of upper extremity claudication especially upon exertion, dizziness, visual changes, vertigo or chest pain depending on etiology. Intervention in all cases is based on presenting symptoms and ranges from percutaneous transluminal angiography and stenting (PTAS) to open surgical bypass, usually carotid-subclavian bypass or transposition. Over the years, the paradigm has been shifting from open to endoluminal repair, with many studies showing similar technical success rates albeit limited long-term patency . While open surgery continues to show better long-term patency versus endoluminal treatment, the risks associated with open revascularization are significantly greater . Further, in cases with challenging arch anatomy or tortuous vessels, the endoluminal approach is often unsuccessful or aborted in favor of open surgical repair . We present a case of a subclavian stenosis with upper extremity ischemia in a patient with difficult type II aortic arch (with acute angulation of the subclavian artery origin) and a 3-mm brachial artery. Endoluminal repair using through-and-through access via the brachial or radial artery and the femoral artery (“flossing technique”) is well known. However, we present a new low-profile technique for accessing a small left brachial artery that still allows this technique to be used safely.

2

Case report

The patient, a 68-year-old female, reported a history of chronic left upper extremity cramping pain and easy fatigability with repeated use that was relieved by rest. She denied any dizziness, vertigo or discoloration. Her left upper extremity pulses were nonpalpable.

Subsequent carotid duplex sonography revealed blunted Doppler flow in the left common carotid and internal carotid artery system as well as 50%–79% stenosis of the right internal carotid artery, and a pulse volume recording demonstrated left subclavian arterial disease.

The patient underwent a diagnostic aortic arch angiography, which revealed complete occlusion of the left common carotid artery and confirmed critical disease of the left subclavian artery which arises at an acute angle from the type II aortic arch ( Fig. 1 ). A selective left subclavian arteriogram ( Fig. 2 ) revealed a critical 80% stenosis of the proximal left subclavian artery, with a critical preocclusive 90% diameter stenosis of the left subclavian artery 1 cm beyond the origin of the left vertebral artery. The right common carotid angiogram revealed a 56% diameter stenosis at the origin of right internal carotid artery secondary to eccentric calcified plaque, with a 40% diameter stenosis at the origin of the right external carotid artery. In addition, moderate-to-severe stenosis at the origin of the left vertebral artery and the proximal right renal artery was also found. Based on her symptoms of left upper extremity claudication, percutaneous intervention including stenting of the left subclavian artery was suggested to alleviate the significant stenosis.

Forty-one-degree left anterior oblique arch aortogram demonstrates complete occlusion of the left common carotid artery and confirmed severe disease of the left subclavian artery that arises at an acute angle within a type II aortic arch.

Anteroposterior view: selective left subclavian arteriogram demonstrates 80% critical stenosis of the proximal left subclavian artery, with a critical preocclusive 90% diameter stenosis of the left subclavian artery 1 cm beyond the origin of the left vertebral artery. Arrows highlight stenosis.

The left common femoral artery was accessed (in a separate setting from the diagnostic angiogram), and a 90-cm-length 6-Fr multipurpose tip Pinnacle (Terumo, Tokyo, Japan) destination sheath was advanced over the 260-cm HiWire (Cook, Bloomington, IN, USA) hydrophilic guide wire into the aortic arch.

A 5-Fr vertebral catheter was used to select the left subclavian artery, but repeated attempts to advance the guide wire into the subclavian artery were unsuccessful. This was due to the acute angle made between the aortic arch and the subclavian artery. Eventually, a coronary 300 cm 0.014-in. AllStar (Abbott Vascular, Santa Clara, CA, USA) guide wire was successfully advanced into the left subclavian artery; however, none of the catheters (including a Simmons II catheter) or sheaths could be advanced over this guide wire despite multiple attempts.

In an attempt to facilitate the advancement of catheters into the left subclavian artery by dilating the proximal critical stenosis, a 3.5-mm-diameter×20-mm-length Maverick (Scimed, Natick, MA, USA) monorail coronary balloon was tried, but the monorail balloon was unable to advance over the guide wire due to kinking of the monorail shaft. Similar attempts with a Rival (Bard, Murray Hill, NJ, USA) 4.0-mm-diameter 2.0-cm balloon were unsuccessful.

It was therefore decided to obtain through-and-through access via a left brachial artery approach. The left brachial artery was accessed in the usual manner under real-time sonographic guidance, and its patency was confirmed. A 21-gauge Micropuncture (Cook) needle was utilized to puncture the left brachial artery under real-time ultrasound guidance, and a 0.018-in. guide wire was advanced into the artery. Only the 3-Fr inner dilator portion of the Silhouette Transitionless Micropuncture Introducer Set (Cook) without its outer sheath was advanced over the guide wire. [Of note, the Micropuncture Push-Plus Introducer Set (Cook) with a stiffened cannula cannot be used in this technique.]

Next, a second 300-cm 0.014-in. coronary AllStar (Abbott Vascular) guide wire was advanced in a retrograde fashion through the left brachial artery access past the critical stenosis within the distal left subclavian artery as well as the critical stenosis within the proximal left subclavian artery. The guide wire was advanced into the aortic arch where it was snared through the 6-Fr guiding sheath using a 12-mm to 20-mm EN Snare (Merit Medical, South Jordan, UT, USA). This allowed through-and-through access utilizing 300-cm AllStar 0.014-in. coronary guide wire.

Next, a left subclavian arteriogram ( Fig. 3 ) was performed using the 6-Fr pinnacle destination sheath that revealed a critical 80% stenosis within the proximal left subclavian artery as well as the preocclusive 90% stenosis within the left subclavian artery distally.

Anteroposterior view: selective left subclavian arteriogram following through-and-through access demonstrates a critical 80% stenosis within the proximal left subclavian artery as well as the preocclusive 90% stenosis within the left subclavian artery distally.

Percutaneous transluminal angioplasty was then performed across the proximal critical 80% stenosis and the distal critical 90% preocclusive stenosis within the left subclavian artery utilizing a 5.0-mm-diameter×2-cm Rival (Bard) balloon. But the suboptimal angiographic result following each of these angioplasties led to the deployment of a 6.0-mm-diameter 20-mm Formula 418 (Cook) biliary stent across the distal stenosis.

The proximal critical 80% stenosis was similarly treated with 7.0-mm-diameter×20-mm-length Formula 418 biliary stent. Both stents were postdilated to nominal diameters using 12.0 atm of pressure. There was a good angiographic result again ( Fig. 4 ), apart from a mild stenosis due to residual plaque between these stents, which was not treated for the fear of embolization and potential of the plaque to be shifted into the origins of the vertebral and internal mammary arteries.

Anteroposterior view: selective left subclavian arteriogram poststenting.

A follow-up angiogram demonstrated patency of left subclavian artery as well as its distal branches in the upper limb (including antegrade flow in the left vertebral and left internal mammary artery). Immediate hemostasis was obtained from the common femoral artery accessed utilizing a StarClose (Abbott Vascular) closure devise. The patient received 6000 U of heparin intravenously during the procedure.

Following the procedure, the patient was monitored for 12 months postprocedure. She has a complete resolution of her left upper extremity easy fatigability and cramping pain. The patient denies any adverse effects except for a small area of ecchymosis postprocedure at the site of the 3-Fr left brachial artery puncture site. She is continuing to tolerate her clopidogrel therapy.