Abstract
Background: Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1–5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA.Objective: To assess the safety and feasibility of a novel technique for distal embolic protection using balloon catheters during SA revascularization with a dual transfemoral and transradial access.Methods: We describe a case series of patients with SSS who underwent SAPTA due to severe stenosis or occlusion of the SA using a combined anterograde/retrograde approach. Transfemoral access to SA was obtained using large bore guide sheaths. Ipsilateral transradial access was obtained using intermediate bore catheters. A Scepter XC balloon catheter was introduced through the transradial intermediate catheter into the ipsilateral VA at the ostium during SAPTA for distal embolic protection.Results: A total of eight patients with SSS underwent subclavian SAPTA. Four patients had the combined anterograde/retrograde approach. Successful revascularization was achieved in three of them. It was difficult to create a channel in the fourth unsuccessful case due to heavily calcified plaque burden. No peri-operative ischemic events were identified. On follow-up, we demonstrated patency of the stents with resolution of symptoms and without any adverse events.Conclusion: Subclavian stenting using a combined transradial and transfemoral access with compliant balloon catheters at the vertebral ostium for prevention of distal emboli may represent an alternative therapeutic approach for the treatment of SA stenosis and occlusions.
Highlights
Subclavian steal syndrome (SSS) is caused by a reversal of flow in the vertebral artery (VA) ipsilateral to a stenosis or occlusion of the prevertebral subclavian artery (SA) [1]
We report four consecutive cases of symptomatic SA occlusion/near occlusions with varying degrees of stenosis, which were treated at our center using a novel combined endovascular technique with both anterograde and retrograde access to SA, while using a balloon catheter in the ipsilateral VA ostium for distal emboli protection
Some researchers propose that endovascular technology is preferable in patients with high-grade stenosis while open bypass is preferable for SA total occlusion [9]; others showed that endovascular therapy is efficient for both with no difference between patients who had stenosis and those who had occlusions based on several case series [6, 8, 21]
Summary
Subclavian steal syndrome (SSS) is caused by a reversal of flow in the vertebral artery (VA) ipsilateral to a stenosis or occlusion of the prevertebral subclavian artery (SA) [1]. Treatment of SA steno-occlusive disease includes either extra-thoracic surgical approaches, or endovascular approaches through stent assisted percutaneous transluminal angioplasty (SAPTA). In comparison with open surgery, endovascular technology demonstrates significantly lower percentage of intraoperative and postoperative complications, and it is carried out under local anesthesia [4, 8, 9]. Patients with an obstructive subclavian artery (SA) may exhibit symptoms of vertebrobasilar insufficiency known as subclavian steal syndrome (SSS). Endovascular treatment with stent assisted percutaneous transluminal angioplasty (SAPTA) demonstrates significantly lower percentage of intraoperative and postoperative complications in comparison with open surgery. There is a 1–5% risk of distal intracranial embolization through the ipsilateral vertebral artery (VA) during SAPTA
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