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Slide 1 - Angioplasty and Stenting of the Great Vessels J. Bayne Selby, Jr., MD Medical University of South Carolina Institut fur Diagnostische und Interventionelle Radiologie Universitat Frankfurt am Main June 7, 2006
Slide 2 - History 1964 First angioplasty report by Dotter and Judkins 1980 First subclavian angioplasty report by Bachman and Kim 1991 Report by Soulen for subclavian angioplasty proximal to LIMA coronary bypass graft 1993 First subclavian stent use reported by Mathias
Slide 3 - Overview Stenoses/occlusion in the great vessels usually represent difficult areas to access surgically Results with angioplasty have been uniformly good in stenoses Use of stents has resulted in similar results for complete occlusions Role of distal embolic protection devices unclear at this time
Slide 4 - 95% Left Subclavian Stenosis Pre Post Post Aortagram
Slide 5 - Left Subclavian Stenosis – Pre, Post, and 6 month follow-up Pre Immediate Post 6 months post
Slide 6 - Patient Selection As always, treatment should only be performed in those patients who have both a hemodynamically significant lesion and appropriate corresponding symptoms
Slide 7 - Anatomic Locations Left Subclavian (most common) Brachiocephalic Left Common Carotid Origin Right Subclavian (often in aberrant vessel)
Slide 8 - Indications Upper Extremity Ischemia Arm Claudication Emboli from lesion to hand Cerebral Ischemia Anterior (carotid) symptoms Vertebro-basilar Insufficiency w/wo subclavian steal Diminished Inflow to Graft Angina in patient with LIMA Claudication in patient with Ax-fem
Slide 9 - Diagnosis Clinical History BLOOD PRESSURES in both arms – simple MRA CTA Conventional Angiography – AP and LAO
Slide 10 - Diagnostic Angiography Evaluate for central lesion (stenosis/occlusion) Evaluate for evidence of distal emboli (then do echocardiography of heart) Evaluate for vasospastic disorder, e.g., Raynaud’s (do angio before and after vasodilator) Evaluate for thoracic outlet syndrome (do abduction and adduction angio)
Slide 11 - Great Vessel Angioplasty/Stent Technique Do baseline neurological exam Initial high quality diagnostic thoracic aortagram Arteriography of distal vascular beds as allowed by degree of disease First attempt to cross lesion from below Use brachial approach if necessary Give Heparin once lesion has been crossed (2,000-3,000 units)
Slide 12 - Great Vessel Angioplasty/Stent Technique Have nurse perform neurological tests on patients at regular intervals (e.g., speak, grip strength, smile, wiggle toes) Use guiding catheter or sheath Try to use appropriate ballon size for initial dilatation, but pre-dilate if lesion is too tight to get across Leave balloon up for 10 seconds Stent for >30% residual stenosis, dissection, recoil Consider primary stent based on appearance of lesion
Slide 13 - Brachiocephalic (Innominate) Artery Angioplasty 99% stenosis at origin of brachiocephalic artery Cross lesion from an axillary approach
Slide 14 - Brachiocephalic (Innominate) Artery Angioplasty 10 mm balloon with “waist” 10 mm balloon fully inflated
Slide 15 - Brachiocephalic (Innominate) Artery Angioplasty Initial 99% stenosis Final with residual stenosis <30% Note post stenotic dilatation
Slide 16 - Subclavian Stenosis proximal to LIMA coronary graft – no stent Diffuse stenosis – poor filling of the LIMA graft S/P Angioplasty – circa 1991
Slide 17 - Stenosis in Single supra-aortic Vessel – Now What?
Slide 18 - Follow up – MR? CT? Angio? Peloschek P., et al. The Role of Multi-slice Spiral CT Angiography in Patient Management After Endovascular Therapy. Cardiovascular and Interventional Radiology, In Press
Slide 19 - Subclavian Stenosis proximal to LIMA coronary graft – with stent
Slide 20 - Stenosis within stent
Slide 21 - Bifurcation Lesions Can occur at right subclavian – right common carotid bifurcation Must use RAO projection to evaluate stenosis Options include: 1) simple angioplasty 2) kissing balloon angioplasty 3) simple stent 4) kissing stents
Slide 22 - Bifurcation Lesions Subclavian Steal 95% stenosis in proximal right subclavian artery
Slide 23 - Bifurcation Lesions Kissing balloon from femoral and right axillary approach Final Result Excellent is the Enemy of Good!
Slide 24 - Bifurcation LesionPulse Volume Recordings Right Arm Left Arm Fingers of Right Hand
Slide 25 - Life Table Analysis30 Subclavian Angioplasty Patients University of Virginia
Slide 26 - Summary of Largest Series of PTA of Brachiocephalic Arterial Stenoses
Slide 27 - Summary of Series of Brachiocephalic Arterial Occlusions
Slide 28 - Complications Puncture site complications, femoral or brachial Rupture of vessel Emboli from angioplasty site Stent misplacement
Slide 29 - Complications Mathias, et al: 38 patients with total occlusions – No significant embolic occlusions
Slide 30 - Complications Literature review by Kachel, et al: 774 supraaortic lesions treated with PTA 0.5% Major complications 3.5% Minor complications
Slide 31 - Explanations 20 second delay in restoration of antegrade flow in vertebral artery following angioplasty – Ringelstein, et al, Nuclear Medicine data Lack of clinical significance of small emboli to hand Possible different response of large vessels to angioplasty/stent (iliac vs. SFA emboli experience)
Slide 32 - Still, now we have protection devices … Landing zone for protection device in supra-aortic angioplasty is often vessel too large Probably should use it when possible
Slide 33 - We’re not done yet!Articles to be published in 2006 6 articles on results of simple angioplasty and/or stenting of great vessels 3 articles on great vessel disease treatment in conjunction with thoracic aortic stent graft 2 articles on percutaneous treatment for arteritis
Slide 34 - Conclusion Angioplasty, with or without stenting is highly effective for stenoses of the great vessels Occlusive disease in the great vessels should always be treated with stent Long term result are excellent (70-90%), but follow –up with CTA upon return of symptoms may be necessary Consider the use of distal embolic protection, although rate of complications has been low without it
Slide 35 - Summary Angioplasty of the Great Vessels can be a useful treatment in a surgically difficult area Results mimic those of the common iliac arteries (>90% success) and have further improved with the use of stents, particularly for occlusions Improvements in technology have increased the technical success in occlusions Complications are low, but remain a hazard – consideration should be given to the use of distal protection devices when anatomy is suitable