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Percutaneous transluminal angioplasty of the subclavian and axillary arteries: Initial results and long term follow-up
Clinical Radiology (1992) 46, I04-107
Percutaneous Transluminal Angioplasty of the Subclavian and Axillary Arteries" Initial Results and Long Term Follow-up C. A. J. R O M A N O W S K I , N. C. F A I R L I E , A. E. P R O C T E R and D. C. C U M B E R L A N D
Department of Medical Imaging, Northern General Hospital, Sheffield The early and long term outcomes of 25 subclavian and axillary angioplasties in a series of 19 patients treated at one centre over a period of 10 years were assessed. The eventual outcome was long lasting improvement in most eases. Two of 25 P T A s were technical failures as defined as > 30% residual stenosis. Twenty-three of 25 P T A s were technical successes: 17 of these were first procedures, one was a repeat after an initial failure, two were repeats for restenosis and three were for separate new lesions. Clinically, 13 of the 19 patients were asymptomatic at long term follow-up. Four had only occasional, mild symptoms (in one of those they were due to shoulder arthropathy). Two patients had technically successful dilatations but developed problems with arterial occlusion distally which in one patient required amputation of that limb. R o m a n o w s k i , C.A.J., Fairlie, N.C., Procter, A.E. & Cumberland, D.C. (1992). Clinical Radiology 15, 104 107. Percutaneous Transluminal Angioplasty of the Subclavian and Axillary Arteries: Initial Results and Long Term Follow-up
Accepted for Publication 13 April 1992
Stenosis or occlusion of the subclavian or axillary arteries is a relatively uncommon manifestation of peripheral vascular disease. It results in a variety of problems including arm claudication, the subclavian steal syndrome, ischaemic fingers due to embolization or even gangrene of the affected limb. In the last decade, percutaneous transluminal angioplasty (PTA) has been used to treat these lesions. P T A is less traumatic than surgery, patients are normally in hospital for a shorter period and the procedure can be repeated if symptoms recur. PTA of the subclavian and axillary arteries has been described elsewhere but the long term outcome has not been fully documented. We have reviewed the late results of angioplasty of these arteries in a series of patients treated at the Northern General Hospital in Sheffield in order to demonstrate the efficacy of this procedure. METHODS PTA of 21 subclavian and 4 axillary arteries was attempted in a consecutive series totalling 11 female and 8 male patients over a period of t0 years. Diagnosis of arterial stenosis or occlusion was made on a combination of clinical assessment, difference in systolic blood pressure measurements between the two arms (range, 10-60 m m H g difference between the two arms; mean difference, 4t m m H g ) and angiography (Fig. 1). Clinical indications included rest pain, intermittent claudication, subclavian steal syndrome, ischaemic changes in the hand due to embolization from the stenosis, Raynaud's phenomenon and paraesthesia (see Table 1). Angiographic indications for PTA were a stenosis of greater than 70'7o diameter reduction of less than 4 cm in length (i.e. not diffuse disease) or occlusions of less than 2 cm in length. Patients in whom disease Correspondence to: Dr C. A. J. Romanowski, Department of Medical Imaging, Northern General Hospital, Herries Road, Sheffield, $5 7AU.
extended into the origin of the vertebral artery were excluded. However, stenoses adjacent to but not compromising the origin of the vertebral artery were not contraindicated even if there was angiographic antegrade filling of this artery and clinical features suggesting distal embolization. Asymptomatic stenosis found incidentally on angiography was not considered for treatment. Angioplasty was performed by the femoral route. Balloon catheters of 6 m m inflated diameter were used for subclavian dilatation in the first five procedures prior to 1986. After this date, when technically possible, 8 m m balloons were used as this was felt to improve the initial post-angioplasty result. Five millimetre balloons were used for all the axillary artery procedures. The angioplasty technique is well described elsewhere [1,2]. Heparin (3000 IU) was given intra-arterially to all patients immediately prior to angioplasty. Following angioplasty, all patients were started on aspirin, 75 150 mg orally once daily. Two patients with angina also had angioplasty of coronary artery stenoses and a third patient had dilatation of a c o m m o n iliac stenosis during the same procedure. Initial assessment was made from the post-angioplasty appearance, success being defined as at most 30% residual diameter stenosis. The long term results of PTA were assessed by directly interviewing the patients or, where this was not possible, by means of a questionnaire filled in by both the patient and their general practitioner. The length of follow-up ranged from 8 months to 10 years (mean of 50.4 months). Each patient's current symptoms were assessed and compared to their original symptoms and any blood pressure difference between the two arms was measured. RESULTS Twenty-five angioplasties patients (Table 1).
were performed
in
19
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY
105
(a) (b) Fig. 1 Subclavian angiogram demonstrating a stenosis distal to the thyrocervical trunk, (a) pre-angioplasty; (b) post-angioplasty.
Immediate Post-Angioplasty Appearance Two of 25 PTAs (EC and K D ) were technical failures ( > 30% residual stenosis). Twenty-three of 25 PTAs were technical successes: 17 of these were first procedures, one was a repeat after an initial failure (KD), two were repeats for restenosis (EN and RL) and three were for separate new lesions (MT, E N and KW). One patient (EC) had a residual stenosis because the distal end could not be adequately dilated. Patient K D had an initial 50% residual stenosis. Because of an unsatisfactory clinical result she underwent a second procedure 5 days later, with technical success, as defined above. All other patients had a technically successful primary procedure with no complications.
Initial Clinical Results One patient (KD) had a positive serum antinuclear factor and a high ESR (81) and was presumed to have a form of vasculitis. Over the few weeks following her second PTA, she had multiple occlusive episodes distal to the angioplasty site (which remained patent) and despite bypass surgery, arm amputation was necessary. Two other patients developed restenosis (EN and RL). RL had a repeat P T A after 1 year. He required amputation of a middle finger that was gangrenous prior to the angioplasty (presumably due to small emboli) and needing surgery regardless of the radiological intervention. EN had an acute restenosis followed by a successful repeat PTA 9 months later.
A further patient (NB) continued to experience arm and shoulder pain but this was later attributed to orthopaedic problems around the shoulder joint. Her original symptoms from subclavian steal syndrome were completely relieved following PTA. In all of the other patients there was early clinical relief of their symptoms and signs.
Long Term Follow-up At follow-up (range 9 years 10 months to 8 months; mean, 50.4 months), 13 of the 19 patients were asymptomatic. Four patients had only occasional, mild symptoms, which in one patient (NB) were due to shoulder arthropathy (see above). Two patients (KC and K D ) had technically successful dilatations but developed problems distally. One patient (KD) required amputation of that limb as documented above. The other patient (KC) was found at repeat angiography 3 months after PTA to have occluded her radial artery in the interval, her radial pulse having been present immediately following the PTA. Her subclavian artery however had remained patent. At follow-up, 10 patients had a blood pressure difference between the two arms of < 10 m m H g . Four patients had a difference of 10-20 m m H g and in only one patient was there a significant difference of 50 m m H g . Such blood pressure measurements were not available in the remaining four patients. In those four patients with occasional mild symptoms, the blood pressure difference
106
CLINICAL RADIOLOGY
Table 1 - Patient data: indications and results
Patient Sex Age Date of Indication procedure
Initial angiographic appearance
Length of follow-up (years and months)
Follow-up symptoms
MT
F
60
17/06/81 Rest pain 29/12/82 Claudication
9y 8
Asymptomatic Asymptomatic
EC NB
F F
70 48
8 6
5 8
KC
F
43
11/11/82 Claudication 19/10/83" Rest pain Subclavian steal 09/12/83 Rest pain
LAS Distal RSS Becoming RAS LSS at vertebral origin Proximal LSS LSS at origin
4
3~"
JF
F
48
22/01/855 Rest pain
6
3
EN
F
45
18/10/85 Rest pain Subclavian steal 14/07/86§ Claudication
Tight LSS at origin extending to vertebral origin Proximal LSO
KW
M
54
14/07/86 Claudication 19/02/86 Rest pain 19/02/86
KD
F
38
09/05/86 14/05/86
JG WS KN
F F M
33 48 53
04/11/86 18/09/87 21/01/88
JH MB RL
M F M
68 78 54
13/05/88 16/11/88 22/05/89 02/05/90¶
RN AG SN BE
M M F M
61 71 54 51
30/06/89 31/07/89 01/09/89 30/04/90
WK
M
63
12/04/91
Restpain and subclavian steal Splinter Haemorrhages and vague pains Raynaud's phenomenon Subclavian steal Claudication Ischaemic fingers Restpain Ischaemicfingers Restpain Gangrenous and ischaemic finger Restpain Claudication Paraesthesia Rest pain and subclavian steal Claudication
LSS at site of previous occlusion RAS LSS at origin and distal subclavian
10 m 4
Eventually asymptomatic Residual mechanical shoulder pain only: No subclavian steal Initially improved but later developed radial artery occlusion Occasional pains Restenosis within 24 h
4 4
9 9
Asymptomatic Asymptomatic
5
0
Occasional pains
5
0
Occasional pains Acute restenosis Eventual amputationll
RSS at origin Proximal LSS Proximal LSS
4 3 3
5 7 3
Asymptomatic Asymptomatic Asymptomatic
Proximal LSS LSS at origin Proximal LSS Proximal LSS
2 2
10 0 10
Asymptomatic Asymptomatic Symptoms recurred Asymptomatic
Proximal LSS RAS Proximal LSS
1 1
9 8 10"t"
Occasional pains Asymptomatic Asymptomatic
LSS at origin Proximal LSS
l
2 8
Proximal RSS LSS LS restenosis
Asymptomatic Asymptomatic
* Right coronary artery stenosis also dilated at same session. "~Lost to follow-up after this initial assessment. Right coronary artery stenosis also dilated at same session. § Right common iliac artery stenosis dilated at same session. 1[Good initial technical result after second dilatation. Occlusion of distal vessels then occurred and despite thrombo-embolectomy and bypass grafting, the limb became gangrenous and was amputated above the elbow. ¶ The left middle finger was gangrenous prior to PTA and was later amputated. L, Left; R, right; SS, subclavian stenosis; AS, axillary stenosis; SO, subclavian occlusion. was 15 m m H g or less. It is also of note that p a t i e n t EC, a l t h o u g h deemed a technical failure, is now a s y m p t o m a tic with a b l o o d pressure difference of < 10 m m H g . DISCUSSION P e r c u t a n e o u s t r a n s l u m i n a l angioplasty of the subclavian a n d axillary artery stenosis is a well established technique [1,3]. R e p o r t e d initial results are good a n d there are clearly a d v a n t a g e s of p a t i e n t tolerance a n d cost effectiveness c o m p a r e d with surgical intervention. The long term results, however, have to be assessed to confirm the role of angioplasty in this clinical setting. In our experience o f 25 s u b c l a v i a n a n d axillary P T A s over a 10 year period, the long term follow-up o n direct review of the patients has shown that in the m a j o r i t y there is long term relief of s y m p t o m s with little or n o difference in measured b l o o d pressure between the two arms. There were n o procedural complications, a l t h o u g h one p a t i e n t ultimately required a m p u t a t i o n of the limb despite a
technically successful PTA. T r e a t m e n t of subclavian or axillary artery stenosis or occlusion by P T A is therefore a safe procedure with good long term effectiveness. Five patients presented with subclavian steal syndrome. M a n y workers have been reluctant to dilate stenoses p r o x i m a l to the origin of the vertebral artery in case embolic material entered the vertebral artery, b u t we have had no neurological complications. It has subseq u e n t l y been s h o w n that the retrograde flow in the vertebral artery does n o t revert back to its n o r m a l antegrade direction until at least 20 s after P T A [4]. T h u s a n y debris w o u l d be carried away from the vertebral artery a n d into the arm. O f further note is that even in o u r patients with a n t e g r a d e vertebral artery flow there were n o neurological sequelae. Three patients presented with trophic changes in the h a n d due to emboli from their stenoses. There was n o clinical evidence of further embolic events in h a n d s either d u r i n g angioplasty or since. It is interesting to speculate that in one p a t i e n t (RL), the P T A converted a rough
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY stenosis, that _was t h r o w i n g off emboli resulting in his g a n g r e n o u s fingers, to a s m o o t h stenosis w i t h o u t subsequent e m b o l i c p h e n o m e n a . This c o u l d t h e r e f o r e a c c o u n t for his lack o f clinical c o m p l a i n t s at f o l l o w - u p despite an objective difference in b l o o d pressure o f 50 m m H g between the two arms. Eleven o f the 19 p a t i e n t s were females, 8 o f w h o m were u n d e r 55 years o f age. T h e r e is a relatively low incidence o f significant a t h e r o s c l e r o t i c vascular disease in this p o p u l a t i o n g r o u p . It is interesting to speculate t h a t stenoses in the s u b c l a v i a n a r t e r y in these y o u n g female patients m a y therefore n o t be atherosclerotic in origin, t h o u g h we have no o t h e r evidence to s u p p o r t this. S o m e o f o u r patients d i d have m a n i f e s t a t i o n s o f a r t e r i a l disease elsewhere a n d we have shown t h a t stenoses in the lower limb or c o r o n a r y arteries m a y be successfully dilated as p a r t o f the s a m e p r o c e d u r e . O u r series also confirms the finding f r o m previous series [3] t h a t the disease process, for u n k n o w n reasons, p r e d o m i n a n t l y affects the left s u b c l a v i a n a r t e r y (in o u r series 16 o f the 18 subclavian arteries diseased were on the left).
107
CONCLUSION A n g i o p l a s t y o f the s u b c l a v i a n and axillary arteries is safe a n d well t o l e r a t e d by patients. L o n g t e r m follow-up (10 years in one instance) indicates that, as in a n g i o p l a s t y elsewhere, recurrence is a relatively early event a n d is r e a d i l y t r e a t a b l e by r e p e a t d i l a t a t i o n . In the subclavian a n d axillary arteries, early p a t e n c y rates are g o o d and eventual long term p a t e n c y c a n be expected. REFERENCES
1 Motarjeme A, Keifer JW, Zuska AJ. Percutaneous transluminal angioplasty of the brachiocephalic arteries. American Journal oJ Radiology 1982; 138: 457-462. 2 Galichia JP, Bajaj AK, Vine DL, Roberts RW. Subclavian artery stenosis treated by transluminal angioplasty; six cases. Cardiovascular and Interventional Radiology 1983; 6:78 81. 3 Cook AM, Dyer JF. Six cases of subclavian stenosis treated by percutaneous angioplasty. Clinical Radiology 1989; 40:352 355. 4 Ringlestein EB, Zeumer H. Delayed reversal of vertebral artery flow following percutaneous transluminal angioplasty for subclavian steal syndrome. Neuroradiology 1984; 26:189 198.
Percutaneous Transluminal Angioplasty of the Subclavian and Axillary Arteries" Initial Results and Long Term Follow-up C. A. J. R O M A N O W S K I , N. C. F A I R L I E , A. E. P R O C T E R and D. C. C U M B E R L A N D
Department of Medical Imaging, Northern General Hospital, Sheffield The early and long term outcomes of 25 subclavian and axillary angioplasties in a series of 19 patients treated at one centre over a period of 10 years were assessed. The eventual outcome was long lasting improvement in most eases. Two of 25 P T A s were technical failures as defined as > 30% residual stenosis. Twenty-three of 25 P T A s were technical successes: 17 of these were first procedures, one was a repeat after an initial failure, two were repeats for restenosis and three were for separate new lesions. Clinically, 13 of the 19 patients were asymptomatic at long term follow-up. Four had only occasional, mild symptoms (in one of those they were due to shoulder arthropathy). Two patients had technically successful dilatations but developed problems with arterial occlusion distally which in one patient required amputation of that limb. R o m a n o w s k i , C.A.J., Fairlie, N.C., Procter, A.E. & Cumberland, D.C. (1992). Clinical Radiology 15, 104 107. Percutaneous Transluminal Angioplasty of the Subclavian and Axillary Arteries: Initial Results and Long Term Follow-up
Accepted for Publication 13 April 1992
Stenosis or occlusion of the subclavian or axillary arteries is a relatively uncommon manifestation of peripheral vascular disease. It results in a variety of problems including arm claudication, the subclavian steal syndrome, ischaemic fingers due to embolization or even gangrene of the affected limb. In the last decade, percutaneous transluminal angioplasty (PTA) has been used to treat these lesions. P T A is less traumatic than surgery, patients are normally in hospital for a shorter period and the procedure can be repeated if symptoms recur. PTA of the subclavian and axillary arteries has been described elsewhere but the long term outcome has not been fully documented. We have reviewed the late results of angioplasty of these arteries in a series of patients treated at the Northern General Hospital in Sheffield in order to demonstrate the efficacy of this procedure. METHODS PTA of 21 subclavian and 4 axillary arteries was attempted in a consecutive series totalling 11 female and 8 male patients over a period of t0 years. Diagnosis of arterial stenosis or occlusion was made on a combination of clinical assessment, difference in systolic blood pressure measurements between the two arms (range, 10-60 m m H g difference between the two arms; mean difference, 4t m m H g ) and angiography (Fig. 1). Clinical indications included rest pain, intermittent claudication, subclavian steal syndrome, ischaemic changes in the hand due to embolization from the stenosis, Raynaud's phenomenon and paraesthesia (see Table 1). Angiographic indications for PTA were a stenosis of greater than 70'7o diameter reduction of less than 4 cm in length (i.e. not diffuse disease) or occlusions of less than 2 cm in length. Patients in whom disease Correspondence to: Dr C. A. J. Romanowski, Department of Medical Imaging, Northern General Hospital, Herries Road, Sheffield, $5 7AU.
extended into the origin of the vertebral artery were excluded. However, stenoses adjacent to but not compromising the origin of the vertebral artery were not contraindicated even if there was angiographic antegrade filling of this artery and clinical features suggesting distal embolization. Asymptomatic stenosis found incidentally on angiography was not considered for treatment. Angioplasty was performed by the femoral route. Balloon catheters of 6 m m inflated diameter were used for subclavian dilatation in the first five procedures prior to 1986. After this date, when technically possible, 8 m m balloons were used as this was felt to improve the initial post-angioplasty result. Five millimetre balloons were used for all the axillary artery procedures. The angioplasty technique is well described elsewhere [1,2]. Heparin (3000 IU) was given intra-arterially to all patients immediately prior to angioplasty. Following angioplasty, all patients were started on aspirin, 75 150 mg orally once daily. Two patients with angina also had angioplasty of coronary artery stenoses and a third patient had dilatation of a c o m m o n iliac stenosis during the same procedure. Initial assessment was made from the post-angioplasty appearance, success being defined as at most 30% residual diameter stenosis. The long term results of PTA were assessed by directly interviewing the patients or, where this was not possible, by means of a questionnaire filled in by both the patient and their general practitioner. The length of follow-up ranged from 8 months to 10 years (mean of 50.4 months). Each patient's current symptoms were assessed and compared to their original symptoms and any blood pressure difference between the two arms was measured. RESULTS Twenty-five angioplasties patients (Table 1).
were performed
in
19
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY
105
(a) (b) Fig. 1 Subclavian angiogram demonstrating a stenosis distal to the thyrocervical trunk, (a) pre-angioplasty; (b) post-angioplasty.
Immediate Post-Angioplasty Appearance Two of 25 PTAs (EC and K D ) were technical failures ( > 30% residual stenosis). Twenty-three of 25 PTAs were technical successes: 17 of these were first procedures, one was a repeat after an initial failure (KD), two were repeats for restenosis (EN and RL) and three were for separate new lesions (MT, E N and KW). One patient (EC) had a residual stenosis because the distal end could not be adequately dilated. Patient K D had an initial 50% residual stenosis. Because of an unsatisfactory clinical result she underwent a second procedure 5 days later, with technical success, as defined above. All other patients had a technically successful primary procedure with no complications.
Initial Clinical Results One patient (KD) had a positive serum antinuclear factor and a high ESR (81) and was presumed to have a form of vasculitis. Over the few weeks following her second PTA, she had multiple occlusive episodes distal to the angioplasty site (which remained patent) and despite bypass surgery, arm amputation was necessary. Two other patients developed restenosis (EN and RL). RL had a repeat P T A after 1 year. He required amputation of a middle finger that was gangrenous prior to the angioplasty (presumably due to small emboli) and needing surgery regardless of the radiological intervention. EN had an acute restenosis followed by a successful repeat PTA 9 months later.
A further patient (NB) continued to experience arm and shoulder pain but this was later attributed to orthopaedic problems around the shoulder joint. Her original symptoms from subclavian steal syndrome were completely relieved following PTA. In all of the other patients there was early clinical relief of their symptoms and signs.
Long Term Follow-up At follow-up (range 9 years 10 months to 8 months; mean, 50.4 months), 13 of the 19 patients were asymptomatic. Four patients had only occasional, mild symptoms, which in one patient (NB) were due to shoulder arthropathy (see above). Two patients (KC and K D ) had technically successful dilatations but developed problems distally. One patient (KD) required amputation of that limb as documented above. The other patient (KC) was found at repeat angiography 3 months after PTA to have occluded her radial artery in the interval, her radial pulse having been present immediately following the PTA. Her subclavian artery however had remained patent. At follow-up, 10 patients had a blood pressure difference between the two arms of < 10 m m H g . Four patients had a difference of 10-20 m m H g and in only one patient was there a significant difference of 50 m m H g . Such blood pressure measurements were not available in the remaining four patients. In those four patients with occasional mild symptoms, the blood pressure difference
106
CLINICAL RADIOLOGY
Table 1 - Patient data: indications and results
Patient Sex Age Date of Indication procedure
Initial angiographic appearance
Length of follow-up (years and months)
Follow-up symptoms
MT
F
60
17/06/81 Rest pain 29/12/82 Claudication
9y 8
Asymptomatic Asymptomatic
EC NB
F F
70 48
8 6
5 8
KC
F
43
11/11/82 Claudication 19/10/83" Rest pain Subclavian steal 09/12/83 Rest pain
LAS Distal RSS Becoming RAS LSS at vertebral origin Proximal LSS LSS at origin
4
3~"
JF
F
48
22/01/855 Rest pain
6
3
EN
F
45
18/10/85 Rest pain Subclavian steal 14/07/86§ Claudication
Tight LSS at origin extending to vertebral origin Proximal LSO
KW
M
54
14/07/86 Claudication 19/02/86 Rest pain 19/02/86
KD
F
38
09/05/86 14/05/86
JG WS KN
F F M
33 48 53
04/11/86 18/09/87 21/01/88
JH MB RL
M F M
68 78 54
13/05/88 16/11/88 22/05/89 02/05/90¶
RN AG SN BE
M M F M
61 71 54 51
30/06/89 31/07/89 01/09/89 30/04/90
WK
M
63
12/04/91
Restpain and subclavian steal Splinter Haemorrhages and vague pains Raynaud's phenomenon Subclavian steal Claudication Ischaemic fingers Restpain Ischaemicfingers Restpain Gangrenous and ischaemic finger Restpain Claudication Paraesthesia Rest pain and subclavian steal Claudication
LSS at site of previous occlusion RAS LSS at origin and distal subclavian
10 m 4
Eventually asymptomatic Residual mechanical shoulder pain only: No subclavian steal Initially improved but later developed radial artery occlusion Occasional pains Restenosis within 24 h
4 4
9 9
Asymptomatic Asymptomatic
5
0
Occasional pains
5
0
Occasional pains Acute restenosis Eventual amputationll
RSS at origin Proximal LSS Proximal LSS
4 3 3
5 7 3
Asymptomatic Asymptomatic Asymptomatic
Proximal LSS LSS at origin Proximal LSS Proximal LSS
2 2
10 0 10
Asymptomatic Asymptomatic Symptoms recurred Asymptomatic
Proximal LSS RAS Proximal LSS
1 1
9 8 10"t"
Occasional pains Asymptomatic Asymptomatic
LSS at origin Proximal LSS
l
2 8
Proximal RSS LSS LS restenosis
Asymptomatic Asymptomatic
* Right coronary artery stenosis also dilated at same session. "~Lost to follow-up after this initial assessment. Right coronary artery stenosis also dilated at same session. § Right common iliac artery stenosis dilated at same session. 1[Good initial technical result after second dilatation. Occlusion of distal vessels then occurred and despite thrombo-embolectomy and bypass grafting, the limb became gangrenous and was amputated above the elbow. ¶ The left middle finger was gangrenous prior to PTA and was later amputated. L, Left; R, right; SS, subclavian stenosis; AS, axillary stenosis; SO, subclavian occlusion. was 15 m m H g or less. It is also of note that p a t i e n t EC, a l t h o u g h deemed a technical failure, is now a s y m p t o m a tic with a b l o o d pressure difference of < 10 m m H g . DISCUSSION P e r c u t a n e o u s t r a n s l u m i n a l angioplasty of the subclavian a n d axillary artery stenosis is a well established technique [1,3]. R e p o r t e d initial results are good a n d there are clearly a d v a n t a g e s of p a t i e n t tolerance a n d cost effectiveness c o m p a r e d with surgical intervention. The long term results, however, have to be assessed to confirm the role of angioplasty in this clinical setting. In our experience o f 25 s u b c l a v i a n a n d axillary P T A s over a 10 year period, the long term follow-up o n direct review of the patients has shown that in the m a j o r i t y there is long term relief of s y m p t o m s with little or n o difference in measured b l o o d pressure between the two arms. There were n o procedural complications, a l t h o u g h one p a t i e n t ultimately required a m p u t a t i o n of the limb despite a
technically successful PTA. T r e a t m e n t of subclavian or axillary artery stenosis or occlusion by P T A is therefore a safe procedure with good long term effectiveness. Five patients presented with subclavian steal syndrome. M a n y workers have been reluctant to dilate stenoses p r o x i m a l to the origin of the vertebral artery in case embolic material entered the vertebral artery, b u t we have had no neurological complications. It has subseq u e n t l y been s h o w n that the retrograde flow in the vertebral artery does n o t revert back to its n o r m a l antegrade direction until at least 20 s after P T A [4]. T h u s a n y debris w o u l d be carried away from the vertebral artery a n d into the arm. O f further note is that even in o u r patients with a n t e g r a d e vertebral artery flow there were n o neurological sequelae. Three patients presented with trophic changes in the h a n d due to emboli from their stenoses. There was n o clinical evidence of further embolic events in h a n d s either d u r i n g angioplasty or since. It is interesting to speculate that in one p a t i e n t (RL), the P T A converted a rough
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY stenosis, that _was t h r o w i n g off emboli resulting in his g a n g r e n o u s fingers, to a s m o o t h stenosis w i t h o u t subsequent e m b o l i c p h e n o m e n a . This c o u l d t h e r e f o r e a c c o u n t for his lack o f clinical c o m p l a i n t s at f o l l o w - u p despite an objective difference in b l o o d pressure o f 50 m m H g between the two arms. Eleven o f the 19 p a t i e n t s were females, 8 o f w h o m were u n d e r 55 years o f age. T h e r e is a relatively low incidence o f significant a t h e r o s c l e r o t i c vascular disease in this p o p u l a t i o n g r o u p . It is interesting to speculate t h a t stenoses in the s u b c l a v i a n a r t e r y in these y o u n g female patients m a y therefore n o t be atherosclerotic in origin, t h o u g h we have no o t h e r evidence to s u p p o r t this. S o m e o f o u r patients d i d have m a n i f e s t a t i o n s o f a r t e r i a l disease elsewhere a n d we have shown t h a t stenoses in the lower limb or c o r o n a r y arteries m a y be successfully dilated as p a r t o f the s a m e p r o c e d u r e . O u r series also confirms the finding f r o m previous series [3] t h a t the disease process, for u n k n o w n reasons, p r e d o m i n a n t l y affects the left s u b c l a v i a n a r t e r y (in o u r series 16 o f the 18 subclavian arteries diseased were on the left).
107
CONCLUSION A n g i o p l a s t y o f the s u b c l a v i a n and axillary arteries is safe a n d well t o l e r a t e d by patients. L o n g t e r m follow-up (10 years in one instance) indicates that, as in a n g i o p l a s t y elsewhere, recurrence is a relatively early event a n d is r e a d i l y t r e a t a b l e by r e p e a t d i l a t a t i o n . In the subclavian a n d axillary arteries, early p a t e n c y rates are g o o d and eventual long term p a t e n c y c a n be expected. REFERENCES
1 Motarjeme A, Keifer JW, Zuska AJ. Percutaneous transluminal angioplasty of the brachiocephalic arteries. American Journal oJ Radiology 1982; 138: 457-462. 2 Galichia JP, Bajaj AK, Vine DL, Roberts RW. Subclavian artery stenosis treated by transluminal angioplasty; six cases. Cardiovascular and Interventional Radiology 1983; 6:78 81. 3 Cook AM, Dyer JF. Six cases of subclavian stenosis treated by percutaneous angioplasty. Clinical Radiology 1989; 40:352 355. 4 Ringlestein EB, Zeumer H. Delayed reversal of vertebral artery flow following percutaneous transluminal angioplasty for subclavian steal syndrome. Neuroradiology 1984; 26:189 198.