Endovascular Therapy As First-Line Management Of Symptomatic High-Grade Inominate-Subclavian Artery Lesions

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edward Y. woo, ronald M. fairman, omaida C. velaquez, michael golden, jagajan karmacharya, jeffrey P. carpenter.
U of pennsylvania, Philadelphia, PA, USA.

Endovascular Therapy as First-line Management of Symptomatic High-grade Inominate-Subclavian Artery Lesions
Introduction: To determine safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions.
Methods: Review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the inominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical exam (pulses and blood pressures) at 1, 3, 6 months and annually plus an annual ultrasound.
Results: Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48-89 years. Symptoms included: vetebrobasilar/steal (15), claudication (6), ischemia (4), CABG/LIMA (2). There were 7 occlusions and 20 high-grade stenoses. Access was obtained via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (6). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 lesions could not be crossed, all of which were occlusions. Furthermore, the remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic BP between arms decreased from 36mmHg(preprocedure) to 8mmHg(postprocedure). There were no procedure-related complications. Mean follow-up was 12 months (range 1-48 months). Three patients were lost to follow-up, and one patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the PTA/stent. Of the four successfully treated occlusions, two were followed out to 3 years with continued patency. Three patients developed recurrent stenoses by duplex exam. However, these patients remained asymptomatic and were not treated.
Conclusion: Endovascular management of high-grade lesions of the subclavian or inominate arteries is safe and efficacious and may be considered as a first-line of therapy. Continued follow-up is needed to assess long-term patency.