- Email: [email protected]
Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-Guiding Catheter for Subclavian Artery Total Occlusion
Accepted Manuscript Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-guiding Catheter for Subclavian Artery Total Occlusion: A Case Report Taiki Yamamoto, MD, Tomotaka Ohshima, MD, PhD, Kojiro Ishikawa, MD, Shunsaku Goto, MD, Yosuke Tamari, MD PII:
S1878-8750(17)30178-X
DOI:
10.1016/j.wneu.2017.02.018
Reference:
WNEU 5249
To appear in:
World Neurosurgery
Received Date: 16 December 2016 Revised Date:
31 January 2017
Accepted Date: 2 February 2017
Please cite this article as: Yamamoto T, Ohshima T, Ishikawa K, Goto S, Tamari Y, Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-guiding Catheter for Subclavian Artery Total Occlusion: A Case Report, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.02.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Yamamoto
ACCEPTED MANUSCRIPT
1
Case report
Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a
RI PT
Balloon-guiding Catheter for Subclavian Artery Total Occlusion: A Case Report
SC
Authors: Taiki Yamamoto1, MD, Tomotaka Ohshima1, MD, PhD, Kojiro Ishikawa1, MD, Shunsaku
1
M AN U
Goto1, MD, and Yosuke Tamari1, MD
Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
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Corresponding author: Tomotaka Ohshima, MD, PhD. 5-15 Sumiyoshi-cho, Kariya, Aichi, 448 8505, Japan. Tel: +81-566-21-2450; Fax: +81-566-22-2493;
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Email: [email protected]
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Keywords: percutaneous transluminal angioplasty, stenting, subclavian artery, subclavian steal syndrome
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Abbreviations: CTO, chronic total occlusion; CT, computed tomography; DWI, diffusion weighted magnetic resonance imaging; EVT, endovascular therapy; F, French; ICA, internal carotid artery;
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transluminal angioplasty; VA, vertebral artery
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MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; PTA, percutaneous
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Conflicts of interest: None.
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ABSTRACT BACKGROUND: Symptomatic subclavian artery total occlusion is widely treated with an
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endovascular procedure, which often results in distal vertebral artery embolism. Therefore,
protection devices are important. Setting up a filter or balloon device in the vertebral artery can
SC
protect against this distal embolism. However, the use of embolic protection devices is not easy and
M AN U
makes the procedure more complicated. Here we report a case of symptomatic subclavian artery
total occlusion that was successfully treated with a balloon-guiding catheter and the pull-through
technique.
CASE DESCRIPTION: A 67-year-old man presented with intermittent motor weakness in his left
TE D
arm. Aortic angiography demonstrated a complete occlusion of the left proximal subclavian artery
and a retrograde flow through the left vertebral artery to the distal brachial artery. In this case, we
EP
used a balloon-guiding catheter and the pull-through technique to prevent distal embolism. The
AC C
balloon-guiding system was useful not only for embolic protection but also for scaffold during
excavation and for the centering effect against invisible vessels. The pull-through technique enabled
our devices to easily and smoothly deliver. The patient was successfully treated without
complications.
CONCLUSIONS: The distal and proximal combined endovascular treatment with a trans-brachial balloon-guiding catheter is a beneficial treatment option for patients with subclavian artery total
Yamamoto
ACCEPTED MANUSCRIPT
4
occlusion.
INTRODUCTION
RI PT
Patients with obstructive subclavian artery atherosclerosis may present with upper extremity claudication, syncope, dizziness, or arm coolness due to subclavian steal syndrome.1 Although
SC
endovascular therapy (EVT) for subclavian artery stenosis is widely performed, there is relatively
little experience of EVT being performed for subclavian artery chronic total occlusion (CTO). This
M AN U
treatment is associated with a risk of distal vertebral artery (VA) embolism;2 therefore, protection
devices are important for EVT. We report a case of symptomatic subclavian artery CTO that was
successfully treated with a trans-brachial balloon-guiding catheter and the pull-through technique
EP
CASE REPORT
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without cerebral infarction.
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A 67-year-old man with a history of hypertension and dyslipidemia presented with intermittent
motor weakness in his left arm; he had experienced dizziness after he was engaged in field work for
3 months. The symptoms worsened with exercise, but improved within some minutes of taking a rest.
A physical examination revealed weak pulsations of the left distal radial artery. There was a 50 mm
Hg difference between blood pressures of the bilateral upper limbs. Diffusion-weighted magnetic
resonance imaging (DWI) showed high-intensity areas in the right occipital and frontal lobes (Fig.
Yamamoto
ACCEPTED MANUSCRIPT
5
1A).
Magnetic resonance angiography (MRA) showed disappearance of the left VA origin (Fig. 1B).
RI PT
Computed tomography (CT) angiography revealed a left subclavian artery occlusion proximal to the
origin of the left VA. Aortic angiography demonstrated complete occlusion of the left proximal
SC
subclavian artery (Fig. 2A), and the right VA angiography revealed the retrograde flow in through
M AN U
the left VA to the distal brachial artery (Fig. 2B). Although a right frontal lobe infarction may have
caused the intermittent motor weakness of the left arm, symptoms worsened on moving the left arm
and was transient only for some minutes. We believe the symptoms were caused by the left
subclavian artery occlusion, and he was diagnosed with the symptomatic subclavian steal syndrome.
TE D
Percutaneous transluminal angioplasty (PTA) and stenting were planned after the diagnosis.
Then, he was administered dual antiplatelet medication (100 mg/day aspirin and 75 mg/day
EP
clopidogrel) for 7 days before EVT.
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Endovascular Procedure
We performed an EVT under local anesthesia wherein we initially punctured both the right
femoral and the left brachial arteries. Heparin was administered to maintain an activated clotting
time of more than 250 sec. A 6-French (F), 90-cm Destination Sheath (Terumo Corporation, Tokyo,
Japan) was placed into the origin of the left subclavian artery and used as the landmark of the
proximal outlet. A 6-F, 90-cm Optimo (Tokai Medical Products, Aichi, Japan) was navigated into the
Yamamoto
ACCEPTED MANUSCRIPT
6
ipsilateral brachial artery and placed at the proximal portion of left VA origin. The balloon at the tip
of the Optimo was inflated for embolic protection (Fig. 3). A 0.035-inch guidewire (Radiforcus;
RI PT
Terumo Corporation, Tokyo, Japan) was inserted via the Optimo and passed through the lesion from
the brachial side (Fig. 4A, B). Next, we navigated an Amplatz GooseNeck Snare (ev3, Plymouth,
SC
MN, USA) from the femoral side. Then, the 0.035-inch guidewire was captured using the snare at
M AN U
the descending aorta and pulled out of the femoral sheath (pull-through technique) (Fig. 5A, B). This
method facilitated an easy and smooth delivery through the devices. Because the diameter of the left
occluded subclavian artery was 6.7 mm and the length of the lesion was 25 mm, a 4 × 40 mm PTA
balloon catheter (Mustang; Boston Scientific, Natick, MA) was selected to predilate for the stent
TE D
placement and advance across the lesion from the femoral side. After predilation with inflating at
nominal pressure, a balloon-expandable stent 7 × 27 mm (EXPRESS VASCULAR LD; Boston
EP
Scientific, Natick, MA) was delivered and deployed in the lesion (Fig. 6). We continuously aspirated
AC C
blood and debris from the tip of the Optimo during the procedure to prevent debris migration. Only
the initially aspirated blood had a little debris after predilation. We found no debris in the blood
aspirated after the stent placement and then deflated the balloon of the Optimo. Postprocedural
aortography, left subclavian artery angiography, and left VA angiography revealed antegrade flow in
the left subclavian artery and VA (Fig. 7).
Postoperative Course
Yamamoto
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7
There were no procedure-related complications. The patient demonstrated no neurological
deficits. Magnetic resonance imaging (MRI) on postoperative day 1 showed no new ischemic lesions.
RI PT
The patient was discharged 7 days after the intervention. Dual antiplatelet therapy was continued for
30 days after the procedure. Subsequently, single antiplatelet therapy with clopidogrel was
SC
indefinitely continued. MRI and echo at his 3-month follow-up revealed no in-stent restenosis.
M AN U
DISCUSSION
In general, subclavian artery stenosis is asymptomatic and is associated with a favorable natural history.3 However, severe subclavian artery stenosis and occlusion can lead to the subclavian steal
syndrome that causes upper claudication, transient ischemic attack, cerebral infarction, syncope,
TE D
vertigo, etc. Symptomatic patients benefit from either PTA with or without stenting, direct surgical
recanalization, or bypass. Current guidelines recommend the endovascular-first strategy in patients
EP
with atherosclerotic lesion of the upper extremities because the primary technical success rate of
AC C
EVT was high and similar to that of surgical treatment and was less invasive than surgical treatment.4 EVT for subclavian artery stenosis is widely performed as an alternative to surgery, and
data published to date suggest a high rate of procedural success with a low rate of major
complications. However, EVT for subclavian artery total occlusion has been confirmed for a small number of case series. The success rate for PTA is lower for total occlusion than that for stenosis.5–7 Liu et al.2 reported that the technical success of EVT for subclavian artery total occlusion was
Yamamoto
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achieved in 77.6% patients, with complications occurring in 6% of them. Their patients in whom an
embolic protection filter device was used showed no complications. Symptomatic infarction of the
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posterior circulation leads to a severe clinical course. Okamoto et al.8 reported that new DWI lesions
were detected in all patients who underwent a non-protection PTA treatment for subclavian artery
SC
total occlusion. This suggests that EVT for subclavian artery total occlusion is associated with a high
complication rate, and embolic protection devices are definitely needed. However, the use of
M AN U
embolic protection devices makes the procedure more complicated.9
In this case, we used an Optimo balloon-guiding catheter via the ipsilateral brachial artery as a
reliable embolic protection device. This method can prevent both cerebral and brachial embolism. In
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addition, the Optimo showed a greater efficacy than what was expected. When a wire crosses the
occluded lesion, the guiding catheter is likely to be kicked back due to a counterforce against the
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organized firm lesion during the excavation. The Optimo guiding catheter is tightly fixed with the
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balloon just at the distal portion of the occluded lesion in the left subclavian artery as an anchor.
Therefore, it is possible to excavate the lesion with a direct force of the wire even if the lesion is
very hard.
The other benefit of the balloon-guiding catheter is the centering effect. Perforation and
dissection of the invisible vessels during digging are the most potentially devastating complications
associated with this operation. Because the Optimo balloon is placed at the tip of the catheter, it can
Yamamoto
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be navigated exactly to the center of the vessel while digging. It is more feasible than what was
expected before experiencing this case.
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Only one case has been reported on the use of the Optimo for subclavian artery total occlusion.10
The authors discussed that the Optimo could prevent a distal embolism to the VA and brachial artery.
SC
On the other hand, Okamoto et al.8 reported a case of DWI on a post EVT for subclavian artery total
M AN U
occlusion that showed new high-intensity areas in the bilateral internal carotid artery (ICA) territory.
They mentioned that the wire and catheter via the brachial artery scratched the arcuate or ascending
aorta wall; this might cause a distal embolism in the ICA territory. Not only the embolic protection
device but also careful manipulations and antithrombotic management are needed to prevent such
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ischemic events.
The Optimo can simplify procedure, and it can also be easily combined with other technique. We
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used the pull-through technique with the Optimo. Although the pull-through technique has been
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previously described, this is the first report using a combination of balloon-guiding catheter and the pull-through technique.9,11–13 This method enabled our devices to easily and smoothly deliver and
could prevent embolism.
Our results showed that a case of symptomatic subclavian artery total occlusion was successfully
treated with a balloon-guiding catheter and the pull-through technique. However, there are some
limitations to this study. It is a single case report of a relatively rare disease. Long-term patency of
Yamamoto 10
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the stent is unknown. Multicenter, randomized, controlled studies with larger cohorts are necessary
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for further evaluations.
CONCLUSIONS
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Distal embolic complication with EVT for subclavian artery total occlusion can result in severe
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symptoms. Therefore, we should be careful to prevent complications using an embolic protection
device. In this case, we used the Optimo balloon-guiding catheter and pull-through technique to
prevent a distal embolism. The patient was successfully treated without complications. The
balloon-guiding system was useful not only for embolic protection but also for scaffold during
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excavation and the centering effect against invisible vessels. The pull-through technique enabled our
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REFERENCES
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devices to easily and smoothly deliver. Examination of more such cases is necessary in future.
1. Lehmann MF, Mounayer C, Benndorf G, Piotin M, Moret J. Pulsatile tinnitus: a symptom of
chronic subclavian artery occlusion. AJNR Am J Neuroradiol. 2005;26:1960-1963.
2. Liu Y, Zhang J, Gu Y, Guo L, Li J. Clinical effectiveness of endovascular therapy for total
occlusion of the subclavian arteries: a study of 67 patients. Ann Vasc Surg. 2016;35:189-196.
3. Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. 2014;129:2320-2323.
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4. Tendera M, Aboyans V, Bartelinl ML, Baumagartner I, Clement D, Collet JP et al. ESC
Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering
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atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower
extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases
SC
of the European Society of Cardiology (ESC). Eur Heart J. 2011:32:2851-2906.
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5. Hebrang A, Maskovic J, Tomac B. Percutaneous transluminal angioplasty of the subclavian
arteries: long-term results in 52 patients. AJR Am J Roentgenol. 1991;156:1091-1094.
6. Motarjeme A. Percutaneous transluminal angioplasty of supra-aortic vessels. J Endovasc Surg.
1996;3:171-181.
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7. Kachel R, Basche S, Heerklotz I, Grossmann K, Endler S. Percutaneous transluminal
angioplasty (PTA) of supra-aortic arteries especially the internal carotid artery. Neuroradiology.
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1991;33:191-194.
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8. Okamoto S, Nakamura M, Mizobe T, Motooka Y, Ashida N, Sugihara M. Percutaneous
transluminal
angioplasty
with
stent
Study
of
postoperative
embolic
lesions
on
diffusion-weighted image. JNET. 2014;8:134-139. (Japanese)
9. Albuquerque FC, Ahmed A, Mitha A, Stiefel M, McDougall CG. Endovascular recanalization
of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and
an argument for embolic protection. World Neurosurg. 2013;80:e327-336.
Yamamoto 12
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10. Nakamura A, Nakajima S, Endo H, Takahashi T, Nozaki E. Subclavian artery intervention with
a balloon-tipped occlusion catheter via the ipsilateral brachial artery without an introducer
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sheath. Cardiovasc Interv Ther. 2015;30:179-184.
11. Gaines PA, Cumberland DC. Wire-loop technique for angioplasty of total iliac artery occlusions.
SC
Radiology. 1988;168:275-276.
percutaneous
angioplasty
of
1989;172:111-113.
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12. Ginsburg R, Thorpe P, Bowles CR, Wright AM, Wexler L. Pull-through approach to
totally
occluded
common
iliac
arteries.
Radiology.
13. Sadato A, Satow T, Ishii A, Ohta T, Hashimoto N. Endovascular recanalization of subclavian
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Figure Legends
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artery occlusions. Neurol Med Chir (Tokyo). 2004;44:447-453.
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Fig. 1. Diffusion-weighted magnetic resonance images (A) on admission demonstrating a
high-intensity area in the right occipital lobe. Magnetic resonance angiography (B) showing
disappearance of the origin of the left vertebral artery (arrow).
Fig. 2. Aortic angiography (A) demonstrating complete occlusion of the left proximal subclavian
artery (arrow). Right vertebral artery angiography (B) demonstrating the retrograde flow in the left
vertebral artery.
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Fig. 3. An angiogram showing the balloon at the tip of the Optimo, which was inflated at the
proximal portion of the left vertebral artery origin under roadmap guidance.
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Fig. 4. (A) A schematic and (B) an angiogram showing the combined approach via the femoral and
brachial sides and inflation of the Optimo balloon and crossing the wire from the brachial side.
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descending aorta and pulling it out of the femoral sheath.
SC
Fig. 5. (A) A schematic and (B) an angiogram showing catching the guidewire using the snare at the
Fig. 6. Implantation of a balloon-expandable stent in the left subclavian artery.
Fig.7. (A) Post-aortic angiography, (B) post-left subclavian artery angiography, and (C) left vertebral
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artery angiography demonstrating antegrade flow in the left subclavian and vertebral arteries.
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Highlights ・We report a case of subclavian artery total occlusion which was treated with a balloon-guiding catheter
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and the pull-through technique. ・The balloon-guiding catheter via the ipsilateral brachial artery can prevent a distal embolism and also prevent the kick back of the catheter itself due to counterforce during a lesion cross.
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・The pull-through technique enabled our devices to easily and smoothly deliver.
S1878-8750(17)30178-X
DOI:
10.1016/j.wneu.2017.02.018
Reference:
WNEU 5249
To appear in:
World Neurosurgery
Received Date: 16 December 2016 Revised Date:
31 January 2017
Accepted Date: 2 February 2017
Please cite this article as: Yamamoto T, Ohshima T, Ishikawa K, Goto S, Tamari Y, Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a Balloon-guiding Catheter for Subclavian Artery Total Occlusion: A Case Report, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.02.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Yamamoto
ACCEPTED MANUSCRIPT
1
Case report
Feasibility and Safety of Distal and Proximal Combined Endovascular Approach with a
RI PT
Balloon-guiding Catheter for Subclavian Artery Total Occlusion: A Case Report
SC
Authors: Taiki Yamamoto1, MD, Tomotaka Ohshima1, MD, PhD, Kojiro Ishikawa1, MD, Shunsaku
1
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Goto1, MD, and Yosuke Tamari1, MD
Department of Neurosurgery, Kariya Toyota General Hospital, Kariya, Japan
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Corresponding author: Tomotaka Ohshima, MD, PhD. 5-15 Sumiyoshi-cho, Kariya, Aichi, 448 8505, Japan. Tel: +81-566-21-2450; Fax: +81-566-22-2493;
EP
Email: [email protected]
AC C
Keywords: percutaneous transluminal angioplasty, stenting, subclavian artery, subclavian steal syndrome
Yamamoto
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Abbreviations: CTO, chronic total occlusion; CT, computed tomography; DWI, diffusion weighted magnetic resonance imaging; EVT, endovascular therapy; F, French; ICA, internal carotid artery;
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transluminal angioplasty; VA, vertebral artery
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MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; PTA, percutaneous
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EP
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Conflicts of interest: None.
Yamamoto
ACCEPTED MANUSCRIPT
3
ABSTRACT BACKGROUND: Symptomatic subclavian artery total occlusion is widely treated with an
RI PT
endovascular procedure, which often results in distal vertebral artery embolism. Therefore,
protection devices are important. Setting up a filter or balloon device in the vertebral artery can
SC
protect against this distal embolism. However, the use of embolic protection devices is not easy and
M AN U
makes the procedure more complicated. Here we report a case of symptomatic subclavian artery
total occlusion that was successfully treated with a balloon-guiding catheter and the pull-through
technique.
CASE DESCRIPTION: A 67-year-old man presented with intermittent motor weakness in his left
TE D
arm. Aortic angiography demonstrated a complete occlusion of the left proximal subclavian artery
and a retrograde flow through the left vertebral artery to the distal brachial artery. In this case, we
EP
used a balloon-guiding catheter and the pull-through technique to prevent distal embolism. The
AC C
balloon-guiding system was useful not only for embolic protection but also for scaffold during
excavation and for the centering effect against invisible vessels. The pull-through technique enabled
our devices to easily and smoothly deliver. The patient was successfully treated without
complications.
CONCLUSIONS: The distal and proximal combined endovascular treatment with a trans-brachial balloon-guiding catheter is a beneficial treatment option for patients with subclavian artery total
Yamamoto
ACCEPTED MANUSCRIPT
4
occlusion.
INTRODUCTION
RI PT
Patients with obstructive subclavian artery atherosclerosis may present with upper extremity claudication, syncope, dizziness, or arm coolness due to subclavian steal syndrome.1 Although
SC
endovascular therapy (EVT) for subclavian artery stenosis is widely performed, there is relatively
little experience of EVT being performed for subclavian artery chronic total occlusion (CTO). This
M AN U
treatment is associated with a risk of distal vertebral artery (VA) embolism;2 therefore, protection
devices are important for EVT. We report a case of symptomatic subclavian artery CTO that was
successfully treated with a trans-brachial balloon-guiding catheter and the pull-through technique
EP
CASE REPORT
TE D
without cerebral infarction.
AC C
A 67-year-old man with a history of hypertension and dyslipidemia presented with intermittent
motor weakness in his left arm; he had experienced dizziness after he was engaged in field work for
3 months. The symptoms worsened with exercise, but improved within some minutes of taking a rest.
A physical examination revealed weak pulsations of the left distal radial artery. There was a 50 mm
Hg difference between blood pressures of the bilateral upper limbs. Diffusion-weighted magnetic
resonance imaging (DWI) showed high-intensity areas in the right occipital and frontal lobes (Fig.
Yamamoto
ACCEPTED MANUSCRIPT
5
1A).
Magnetic resonance angiography (MRA) showed disappearance of the left VA origin (Fig. 1B).
RI PT
Computed tomography (CT) angiography revealed a left subclavian artery occlusion proximal to the
origin of the left VA. Aortic angiography demonstrated complete occlusion of the left proximal
SC
subclavian artery (Fig. 2A), and the right VA angiography revealed the retrograde flow in through
M AN U
the left VA to the distal brachial artery (Fig. 2B). Although a right frontal lobe infarction may have
caused the intermittent motor weakness of the left arm, symptoms worsened on moving the left arm
and was transient only for some minutes. We believe the symptoms were caused by the left
subclavian artery occlusion, and he was diagnosed with the symptomatic subclavian steal syndrome.
TE D
Percutaneous transluminal angioplasty (PTA) and stenting were planned after the diagnosis.
Then, he was administered dual antiplatelet medication (100 mg/day aspirin and 75 mg/day
EP
clopidogrel) for 7 days before EVT.
AC C
Endovascular Procedure
We performed an EVT under local anesthesia wherein we initially punctured both the right
femoral and the left brachial arteries. Heparin was administered to maintain an activated clotting
time of more than 250 sec. A 6-French (F), 90-cm Destination Sheath (Terumo Corporation, Tokyo,
Japan) was placed into the origin of the left subclavian artery and used as the landmark of the
proximal outlet. A 6-F, 90-cm Optimo (Tokai Medical Products, Aichi, Japan) was navigated into the
Yamamoto
ACCEPTED MANUSCRIPT
6
ipsilateral brachial artery and placed at the proximal portion of left VA origin. The balloon at the tip
of the Optimo was inflated for embolic protection (Fig. 3). A 0.035-inch guidewire (Radiforcus;
RI PT
Terumo Corporation, Tokyo, Japan) was inserted via the Optimo and passed through the lesion from
the brachial side (Fig. 4A, B). Next, we navigated an Amplatz GooseNeck Snare (ev3, Plymouth,
SC
MN, USA) from the femoral side. Then, the 0.035-inch guidewire was captured using the snare at
M AN U
the descending aorta and pulled out of the femoral sheath (pull-through technique) (Fig. 5A, B). This
method facilitated an easy and smooth delivery through the devices. Because the diameter of the left
occluded subclavian artery was 6.7 mm and the length of the lesion was 25 mm, a 4 × 40 mm PTA
balloon catheter (Mustang; Boston Scientific, Natick, MA) was selected to predilate for the stent
TE D
placement and advance across the lesion from the femoral side. After predilation with inflating at
nominal pressure, a balloon-expandable stent 7 × 27 mm (EXPRESS VASCULAR LD; Boston
EP
Scientific, Natick, MA) was delivered and deployed in the lesion (Fig. 6). We continuously aspirated
AC C
blood and debris from the tip of the Optimo during the procedure to prevent debris migration. Only
the initially aspirated blood had a little debris after predilation. We found no debris in the blood
aspirated after the stent placement and then deflated the balloon of the Optimo. Postprocedural
aortography, left subclavian artery angiography, and left VA angiography revealed antegrade flow in
the left subclavian artery and VA (Fig. 7).
Postoperative Course
Yamamoto
ACCEPTED MANUSCRIPT
7
There were no procedure-related complications. The patient demonstrated no neurological
deficits. Magnetic resonance imaging (MRI) on postoperative day 1 showed no new ischemic lesions.
RI PT
The patient was discharged 7 days after the intervention. Dual antiplatelet therapy was continued for
30 days after the procedure. Subsequently, single antiplatelet therapy with clopidogrel was
SC
indefinitely continued. MRI and echo at his 3-month follow-up revealed no in-stent restenosis.
M AN U
DISCUSSION
In general, subclavian artery stenosis is asymptomatic and is associated with a favorable natural history.3 However, severe subclavian artery stenosis and occlusion can lead to the subclavian steal
syndrome that causes upper claudication, transient ischemic attack, cerebral infarction, syncope,
TE D
vertigo, etc. Symptomatic patients benefit from either PTA with or without stenting, direct surgical
recanalization, or bypass. Current guidelines recommend the endovascular-first strategy in patients
EP
with atherosclerotic lesion of the upper extremities because the primary technical success rate of
AC C
EVT was high and similar to that of surgical treatment and was less invasive than surgical treatment.4 EVT for subclavian artery stenosis is widely performed as an alternative to surgery, and
data published to date suggest a high rate of procedural success with a low rate of major
complications. However, EVT for subclavian artery total occlusion has been confirmed for a small number of case series. The success rate for PTA is lower for total occlusion than that for stenosis.5–7 Liu et al.2 reported that the technical success of EVT for subclavian artery total occlusion was
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achieved in 77.6% patients, with complications occurring in 6% of them. Their patients in whom an
embolic protection filter device was used showed no complications. Symptomatic infarction of the
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posterior circulation leads to a severe clinical course. Okamoto et al.8 reported that new DWI lesions
were detected in all patients who underwent a non-protection PTA treatment for subclavian artery
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total occlusion. This suggests that EVT for subclavian artery total occlusion is associated with a high
complication rate, and embolic protection devices are definitely needed. However, the use of
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embolic protection devices makes the procedure more complicated.9
In this case, we used an Optimo balloon-guiding catheter via the ipsilateral brachial artery as a
reliable embolic protection device. This method can prevent both cerebral and brachial embolism. In
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addition, the Optimo showed a greater efficacy than what was expected. When a wire crosses the
occluded lesion, the guiding catheter is likely to be kicked back due to a counterforce against the
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organized firm lesion during the excavation. The Optimo guiding catheter is tightly fixed with the
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balloon just at the distal portion of the occluded lesion in the left subclavian artery as an anchor.
Therefore, it is possible to excavate the lesion with a direct force of the wire even if the lesion is
very hard.
The other benefit of the balloon-guiding catheter is the centering effect. Perforation and
dissection of the invisible vessels during digging are the most potentially devastating complications
associated with this operation. Because the Optimo balloon is placed at the tip of the catheter, it can
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be navigated exactly to the center of the vessel while digging. It is more feasible than what was
expected before experiencing this case.
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Only one case has been reported on the use of the Optimo for subclavian artery total occlusion.10
The authors discussed that the Optimo could prevent a distal embolism to the VA and brachial artery.
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On the other hand, Okamoto et al.8 reported a case of DWI on a post EVT for subclavian artery total
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occlusion that showed new high-intensity areas in the bilateral internal carotid artery (ICA) territory.
They mentioned that the wire and catheter via the brachial artery scratched the arcuate or ascending
aorta wall; this might cause a distal embolism in the ICA territory. Not only the embolic protection
device but also careful manipulations and antithrombotic management are needed to prevent such
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ischemic events.
The Optimo can simplify procedure, and it can also be easily combined with other technique. We
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used the pull-through technique with the Optimo. Although the pull-through technique has been
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previously described, this is the first report using a combination of balloon-guiding catheter and the pull-through technique.9,11–13 This method enabled our devices to easily and smoothly deliver and
could prevent embolism.
Our results showed that a case of symptomatic subclavian artery total occlusion was successfully
treated with a balloon-guiding catheter and the pull-through technique. However, there are some
limitations to this study. It is a single case report of a relatively rare disease. Long-term patency of
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the stent is unknown. Multicenter, randomized, controlled studies with larger cohorts are necessary
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for further evaluations.
CONCLUSIONS
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Distal embolic complication with EVT for subclavian artery total occlusion can result in severe
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symptoms. Therefore, we should be careful to prevent complications using an embolic protection
device. In this case, we used the Optimo balloon-guiding catheter and pull-through technique to
prevent a distal embolism. The patient was successfully treated without complications. The
balloon-guiding system was useful not only for embolic protection but also for scaffold during
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excavation and the centering effect against invisible vessels. The pull-through technique enabled our
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REFERENCES
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devices to easily and smoothly deliver. Examination of more such cases is necessary in future.
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2. Liu Y, Zhang J, Gu Y, Guo L, Li J. Clinical effectiveness of endovascular therapy for total
occlusion of the subclavian arteries: a study of 67 patients. Ann Vasc Surg. 2016;35:189-196.
3. Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. 2014;129:2320-2323.
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4. Tendera M, Aboyans V, Bartelinl ML, Baumagartner I, Clement D, Collet JP et al. ESC
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8. Okamoto S, Nakamura M, Mizobe T, Motooka Y, Ashida N, Sugihara M. Percutaneous
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9. Albuquerque FC, Ahmed A, Mitha A, Stiefel M, McDougall CG. Endovascular recanalization
of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and
an argument for embolic protection. World Neurosurg. 2013;80:e327-336.
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10. Nakamura A, Nakajima S, Endo H, Takahashi T, Nozaki E. Subclavian artery intervention with
a balloon-tipped occlusion catheter via the ipsilateral brachial artery without an introducer
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sheath. Cardiovasc Interv Ther. 2015;30:179-184.
11. Gaines PA, Cumberland DC. Wire-loop technique for angioplasty of total iliac artery occlusions.
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12. Ginsburg R, Thorpe P, Bowles CR, Wright AM, Wexler L. Pull-through approach to
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Figure Legends
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artery occlusions. Neurol Med Chir (Tokyo). 2004;44:447-453.
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Fig. 1. Diffusion-weighted magnetic resonance images (A) on admission demonstrating a
high-intensity area in the right occipital lobe. Magnetic resonance angiography (B) showing
disappearance of the origin of the left vertebral artery (arrow).
Fig. 2. Aortic angiography (A) demonstrating complete occlusion of the left proximal subclavian
artery (arrow). Right vertebral artery angiography (B) demonstrating the retrograde flow in the left
vertebral artery.
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Fig. 3. An angiogram showing the balloon at the tip of the Optimo, which was inflated at the
proximal portion of the left vertebral artery origin under roadmap guidance.
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Fig. 4. (A) A schematic and (B) an angiogram showing the combined approach via the femoral and
brachial sides and inflation of the Optimo balloon and crossing the wire from the brachial side.
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descending aorta and pulling it out of the femoral sheath.
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Fig. 5. (A) A schematic and (B) an angiogram showing catching the guidewire using the snare at the
Fig. 6. Implantation of a balloon-expandable stent in the left subclavian artery.
Fig.7. (A) Post-aortic angiography, (B) post-left subclavian artery angiography, and (C) left vertebral
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artery angiography demonstrating antegrade flow in the left subclavian and vertebral arteries.
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Highlights ・We report a case of subclavian artery total occlusion which was treated with a balloon-guiding catheter
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and the pull-through technique. ・The balloon-guiding catheter via the ipsilateral brachial artery can prevent a distal embolism and also prevent the kick back of the catheter itself due to counterforce during a lesion cross.
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・The pull-through technique enabled our devices to easily and smoothly deliver.