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Initial and Long-term Results of Brachiocephalic and Subclavian Interventions
Wednesday, March 6, 1996
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cation rate is much higher due to the many perforating arteries that supply critical vascular territories of the cerebral cortex, brain stem, and upper cervical spinal cord. Conclusion Cerebral PTA techniques appear favorable for treatment of high-grade stenotic lesions that involve both the extracranial and intracranial cerebral circulation and are refractory to medical treatment. In patients who present with acute stroke symptoms and have documented complete occlusion or acute intraluminal thrombus, direct intraarterial thrombolysis before angioplasty is feasible. In patients with acute arterial dissection, vessel rupture, or abrupt closure, stent deployment for recanalization is also feasible.
However, long-term follow-up to assess the efficacy of balloon angioplasty therapy and intravascular stenting is still ongoing. Comparison studies between medical, surgical, and percutaneous transluminal cerebral angioplasty techniques for comparable groups of patients will be needed to define further this treatment modality as a usable option for clinically symptomatic patients in all of the different vascular territories now accessible by PTA.
Selected Bibliography Acheson], Hutchinson EC. The natural history of focal cerebral vascular disease. Am J Med 1971; 157:15-25. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. Stroke 1994; 25(9} 1901-1914. American Heart Association. 1993 Stroke Facts. Dallas: American Heart Association, 1992. Becker GJ, Katzen BT, Dake MD. Non coronary angioplasty. Radiology 1989; 170:921-940. Bonita R, Beaglehole R. Stroke mortality. In: Stroke: Populations, Cohorts, and Clinical Trials. Whisnant JP, ed. Oxford, England: Butterworth, Heinemann, 1993; 59-79. Cartlidge NE, Whisnant JP, Elueback LR. Carotid and vertebral basilar transient cerebral ischemic attacks. Mayo Clin Proc 1978; 52:117-120. Dyken ML. Stroke risk factors. In: Norris]W, Hachinski VC, eds. Prevention of Stroke. New York: Springer-Verlag, 1991; 83-102. Gallino A, Mahler F, Probst P, et al. Percutaneous transluminal angioplasty of
264
arteries of the lower limbs: 5 year follow up. Circulation 1984; 70:619-623. Goldstein LB, Matchar DB. Clinical assessment of stroke. JAMA 1994; 271:1114-1120. Heros RC. Stroke: early pathophysiology and treatment. Stroke 1994; 25(9):1877-1881. National Advisory Neurological Disorders and Stroke Council. Stroke and cerebrovascular disease. In: Status Report: Decade of the Brain. Bethesda, Md: National Institutes of Health Report, 1992; 26-27. Strandness DE. Surgical therapy for extracranial arterial disease. In: Strandness DE, van Breda A, eds. Vascular Diseases: Surgical and Interventional Therapy. New York: Churchill Livingston, 1994; 643-650.
8:40 am Initial and Long-term Results of Brachiocephalic and Subclavian Interventions Thomas O. McNamara, MD Learning objective: To describe percutaneous transluminal angioplasty of brachiocephalic and subclavian arterial obstructions.
There continues to be considerable apprehension regarding the risk of stroke associated with percutaneous transluminal angioplasty (PTA) of brachiocephalic and subclavian arterial obstructions. In part, this is because most interventionists have much more experience with lesions elsewhere in the vascular tree. The use of PTA to treat such obstructions, however, can result in lesser morbidity, a shorter hospital stay, and no need for anesthesia. initial report on this subject was published in the American Journal ofRoentgenology in 1980. The authors used a Griintzig-type "balloon-tipped catheter" to dilate a tight stenosis in a left subclavian artery. This improved the caliber of the subclavian artery, re-established antegrade flow in the left vertebral artery, raised the systolic pressure in the left arm from 90 to 130 mm Hg, and cleared the marked symptoms of vertebrobasilar insufficiency. No signs or symptoms of arm or brain embolization were noted. Eleven months later, brachial artery pressures were 180/90 bilaterally. Symptoms of dizziness and left arm numbness had not recurred.
An
This initial series represents the experiences that followed. The medical literature now contains reports of more than 1,000 such proce-
Wednesday, March 6, 1996
II
Table 1 Resutlts of PTA of Brachiocephalic Stenoses Author, Year
No. of Lesions
% Success
Stroke
Ann Embolus
17 5 38 30 19 23 21 35 45 139 348
100 80 95 90 90 91 86 100 100 95 97
0 2 (40%) 0 1 (30/0) 0 0 0 0 0 0 1 (0.3%)
0 0 1 (2.6%) 1 (3%) 0 1 (4%) 0 0 0 0 0
Motarjeme, 1985 Derauf, 1986 Vitek, 1986 Burke. 1987 Rossi, 1987 Wilms, 1987 Erbstein, 1988 Vitek, 1988 McNamara, 1991 Kachel, 1993 Mathias, 1993
Restenosis, Follow-up (mo) 0, 60 NA,NA 0, NA 1 (3.7%), 37 2 (12%), 60 3 (14%), 48 3 (14%), 48 NA,NA 0,78 2 (2%), 109 NA,NA
No deaths were reported in any series listed here.
dures involving subclavian, innominate, vertebral, and common carotid arteries. Table 1 lists results from many larger published series. Results with brachiocephalic occlusions have been poor until recently. The advent of hydrophilic guide wires and catheters, as well as stents, has increased success rates. Initial success has increased from 20% to 83%. The longterm patency rates have increased from 30% to 100% (33 months), according to Mathias. PTA of stenoses of brachiocephalic arteries (excluding carotid bifurcations) has been associated with a low incidence of complications, including stroke, and no mortality. It is associated with a low incidence of restenosis. Recent advances suggest that similar results can be expected for occlusions if stents are used.
Sellected Bibliography Bachman DM, Kim RM. Transluminal dilatation for subclavian steal syndrome. AJR 1980; 135:995-996. Burke DR, Gordon RL, Mishkin JD, McLean GK, Meranze SG. Percutaneous transluminal angioplasty of subclavian arteries. Radiology 1987; 164:699-704. Derauf BJ, Erickson DL, Castaneda-Zuniga WR, Cardella J, Amplatz K. "Washout" technique for brachiocephalic angioplasty. AJR 1986; 146:849-851. Kachel R. Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially of the carotid and vertebral artery: alternative to vascular surgery? J Malad Vascul 1993; 18 (3):254-257. Mathias K, LOth I, Haarman P. Percutaneous transluminal angioplasty of proximal subclavian artery occlusions. Cardiovasc Intervent Radiol 1993; 16:214-218.
McNamara TO. Angioplasty of Stenoses of the Proximal Upper Extremity and Cranial Vessels in Current Practice of Interventional Radiology. Philadelphia, BC Decker, 1991; 261-271. Motarjeme A, Keiter )W, Zuska AJ, Nabawi P. Percutaneous transluminal angioplasty for treatment of subclavian steal. Radiology 1985; 155:611-613. Rossi P, Sciacca V, Castrucci M, et al. Percutaneous transluminal angioplasty of subclavian artery: comparative study with axillo-contralateral bypass. Ann Radiol 1987; 31:87-91. Vitek J. Subclavian artery angioplasty and the origin of the vertebral artery. Radiology 1989; 170:407-409. Vitek JJ, Keller FS, Duvall ER, Gupta KL, Chandra-Sekar B. Brachiocephalic artery dilatation by percutaneous transluminal angioplasty. Radiology 1986; 158:779-785. Wilms G, Baert A, Dewaele D, Vermylen J, Nevelsteen A, Suy R. Percutaneous transluminal angioplasty of the subclavian artery: early and late results. Cardiovasc Intervent Radiol 1987; 10:123-128. 9:00 am
Extracranial Angioplasty Donald E. Schwarten, MD Learning objective: To describe extracranial angioplasty and examine its appropriate use for treatment of atherosclerotic disease involving the cerebral vessels. Percutaneous transluminal angioplasty (PTA) is a well-accepted technique for treating arterial occlusive disease in all anatomic territories except the cerebral vessels. The application of
265
II
cation rate is much higher due to the many perforating arteries that supply critical vascular territories of the cerebral cortex, brain stem, and upper cervical spinal cord. Conclusion Cerebral PTA techniques appear favorable for treatment of high-grade stenotic lesions that involve both the extracranial and intracranial cerebral circulation and are refractory to medical treatment. In patients who present with acute stroke symptoms and have documented complete occlusion or acute intraluminal thrombus, direct intraarterial thrombolysis before angioplasty is feasible. In patients with acute arterial dissection, vessel rupture, or abrupt closure, stent deployment for recanalization is also feasible.
However, long-term follow-up to assess the efficacy of balloon angioplasty therapy and intravascular stenting is still ongoing. Comparison studies between medical, surgical, and percutaneous transluminal cerebral angioplasty techniques for comparable groups of patients will be needed to define further this treatment modality as a usable option for clinically symptomatic patients in all of the different vascular territories now accessible by PTA.
Selected Bibliography Acheson], Hutchinson EC. The natural history of focal cerebral vascular disease. Am J Med 1971; 157:15-25. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. Stroke 1994; 25(9} 1901-1914. American Heart Association. 1993 Stroke Facts. Dallas: American Heart Association, 1992. Becker GJ, Katzen BT, Dake MD. Non coronary angioplasty. Radiology 1989; 170:921-940. Bonita R, Beaglehole R. Stroke mortality. In: Stroke: Populations, Cohorts, and Clinical Trials. Whisnant JP, ed. Oxford, England: Butterworth, Heinemann, 1993; 59-79. Cartlidge NE, Whisnant JP, Elueback LR. Carotid and vertebral basilar transient cerebral ischemic attacks. Mayo Clin Proc 1978; 52:117-120. Dyken ML. Stroke risk factors. In: Norris]W, Hachinski VC, eds. Prevention of Stroke. New York: Springer-Verlag, 1991; 83-102. Gallino A, Mahler F, Probst P, et al. Percutaneous transluminal angioplasty of
264
arteries of the lower limbs: 5 year follow up. Circulation 1984; 70:619-623. Goldstein LB, Matchar DB. Clinical assessment of stroke. JAMA 1994; 271:1114-1120. Heros RC. Stroke: early pathophysiology and treatment. Stroke 1994; 25(9):1877-1881. National Advisory Neurological Disorders and Stroke Council. Stroke and cerebrovascular disease. In: Status Report: Decade of the Brain. Bethesda, Md: National Institutes of Health Report, 1992; 26-27. Strandness DE. Surgical therapy for extracranial arterial disease. In: Strandness DE, van Breda A, eds. Vascular Diseases: Surgical and Interventional Therapy. New York: Churchill Livingston, 1994; 643-650.
8:40 am Initial and Long-term Results of Brachiocephalic and Subclavian Interventions Thomas O. McNamara, MD Learning objective: To describe percutaneous transluminal angioplasty of brachiocephalic and subclavian arterial obstructions.
There continues to be considerable apprehension regarding the risk of stroke associated with percutaneous transluminal angioplasty (PTA) of brachiocephalic and subclavian arterial obstructions. In part, this is because most interventionists have much more experience with lesions elsewhere in the vascular tree. The use of PTA to treat such obstructions, however, can result in lesser morbidity, a shorter hospital stay, and no need for anesthesia. initial report on this subject was published in the American Journal ofRoentgenology in 1980. The authors used a Griintzig-type "balloon-tipped catheter" to dilate a tight stenosis in a left subclavian artery. This improved the caliber of the subclavian artery, re-established antegrade flow in the left vertebral artery, raised the systolic pressure in the left arm from 90 to 130 mm Hg, and cleared the marked symptoms of vertebrobasilar insufficiency. No signs or symptoms of arm or brain embolization were noted. Eleven months later, brachial artery pressures were 180/90 bilaterally. Symptoms of dizziness and left arm numbness had not recurred.
An
This initial series represents the experiences that followed. The medical literature now contains reports of more than 1,000 such proce-
Wednesday, March 6, 1996
II
Table 1 Resutlts of PTA of Brachiocephalic Stenoses Author, Year
No. of Lesions
% Success
Stroke
Ann Embolus
17 5 38 30 19 23 21 35 45 139 348
100 80 95 90 90 91 86 100 100 95 97
0 2 (40%) 0 1 (30/0) 0 0 0 0 0 0 1 (0.3%)
0 0 1 (2.6%) 1 (3%) 0 1 (4%) 0 0 0 0 0
Motarjeme, 1985 Derauf, 1986 Vitek, 1986 Burke. 1987 Rossi, 1987 Wilms, 1987 Erbstein, 1988 Vitek, 1988 McNamara, 1991 Kachel, 1993 Mathias, 1993
Restenosis, Follow-up (mo) 0, 60 NA,NA 0, NA 1 (3.7%), 37 2 (12%), 60 3 (14%), 48 3 (14%), 48 NA,NA 0,78 2 (2%), 109 NA,NA
No deaths were reported in any series listed here.
dures involving subclavian, innominate, vertebral, and common carotid arteries. Table 1 lists results from many larger published series. Results with brachiocephalic occlusions have been poor until recently. The advent of hydrophilic guide wires and catheters, as well as stents, has increased success rates. Initial success has increased from 20% to 83%. The longterm patency rates have increased from 30% to 100% (33 months), according to Mathias. PTA of stenoses of brachiocephalic arteries (excluding carotid bifurcations) has been associated with a low incidence of complications, including stroke, and no mortality. It is associated with a low incidence of restenosis. Recent advances suggest that similar results can be expected for occlusions if stents are used.
Sellected Bibliography Bachman DM, Kim RM. Transluminal dilatation for subclavian steal syndrome. AJR 1980; 135:995-996. Burke DR, Gordon RL, Mishkin JD, McLean GK, Meranze SG. Percutaneous transluminal angioplasty of subclavian arteries. Radiology 1987; 164:699-704. Derauf BJ, Erickson DL, Castaneda-Zuniga WR, Cardella J, Amplatz K. "Washout" technique for brachiocephalic angioplasty. AJR 1986; 146:849-851. Kachel R. Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially of the carotid and vertebral artery: alternative to vascular surgery? J Malad Vascul 1993; 18 (3):254-257. Mathias K, LOth I, Haarman P. Percutaneous transluminal angioplasty of proximal subclavian artery occlusions. Cardiovasc Intervent Radiol 1993; 16:214-218.
McNamara TO. Angioplasty of Stenoses of the Proximal Upper Extremity and Cranial Vessels in Current Practice of Interventional Radiology. Philadelphia, BC Decker, 1991; 261-271. Motarjeme A, Keiter )W, Zuska AJ, Nabawi P. Percutaneous transluminal angioplasty for treatment of subclavian steal. Radiology 1985; 155:611-613. Rossi P, Sciacca V, Castrucci M, et al. Percutaneous transluminal angioplasty of subclavian artery: comparative study with axillo-contralateral bypass. Ann Radiol 1987; 31:87-91. Vitek J. Subclavian artery angioplasty and the origin of the vertebral artery. Radiology 1989; 170:407-409. Vitek JJ, Keller FS, Duvall ER, Gupta KL, Chandra-Sekar B. Brachiocephalic artery dilatation by percutaneous transluminal angioplasty. Radiology 1986; 158:779-785. Wilms G, Baert A, Dewaele D, Vermylen J, Nevelsteen A, Suy R. Percutaneous transluminal angioplasty of the subclavian artery: early and late results. Cardiovasc Intervent Radiol 1987; 10:123-128. 9:00 am
Extracranial Angioplasty Donald E. Schwarten, MD Learning objective: To describe extracranial angioplasty and examine its appropriate use for treatment of atherosclerotic disease involving the cerebral vessels. Percutaneous transluminal angioplasty (PTA) is a well-accepted technique for treating arterial occlusive disease in all anatomic territories except the cerebral vessels. The application of
265