Subclavian artery disease
Editors-In-Chief: Alexandra Almonacid M.D.[1] and Jeffrey J. Popma M.D.[2]
Etiology
- Atherosclerosis
- Most common cause of subclavian artery stenosis
- Predilection for the proximal part of the artery
- The occlusion usually extends from the aortic arch to the origin of the vertebral artery due to poor collateral circulation
- Takayasu's Arteritis
- Fibromuscular dysplasia
- Giant Cell Arteritis
- Radiation-induced Vascular Injury
- Thoracic Outlet Syndrome
- Neurofibromatosis
Epidemiology and Demographics
- Incidence of 0.5 - 2% (1)
- Left : Right = 3-4 : 1 ratio
- The stenosis is usually focal and in the proximal segment of the vessel
- Predictors:Hypertension, Tobacco use, Dyslipidemia, and Diabetes.
Complications
- Hematomas
- Subclavian thrombosis
- Axillary artery thrombosis
- Stent Migration
- Arterial rupture
- Dissection
- Distal embolization
- Restenosis
- Neurologic complications
- Transient ischemic attack, stroke, hemiplegia, diplopia.
Prognosis
Favorable Predictors
- Presence of subclavian steal syndrome : it prevents the risk of vertebral embolization
- Isolatated stenosis
- Recurrent angina following an internal mammary coronary bypass
Outcomes
Percutaneous transluminal angioplasty appears safe and efficient therapy for subclavian artery stenoses is not only an effective initial treatment, but also successful over the short- and long-term results.
Clinical manifestations
Diagnosis
Clinical Diagnosis
- Obstruction of the subclavian artery is suspected when there is a blood pressure difference > 20mm Hg between the two arms (2)
- If there is a clinical suggestion of vasculitis: an Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP) should be measured (3)
Noninvasive Diagnostic Modalities
- Duplex Ultrasonography
- Duplex ultrasonography of the subclavian artery and the vertebral artery can detect stenosis greater than 50% with a moderately high sensitivity (80% range) and an excellent negative predictive value (> 95%) (4)
- Duplex ultrasonography is also highly useful in clinical follow-up of patients after revascularization procedures (4)
- Diagnostic Imaging: The diagnostic imaging work-up of patients should include:(2)
- Magnetic resonance imaging (MRI) with or without arteriography (MRA)
- Computed tomographic (CT) scan of the brain with close evaluation of the posterior fossa and brainstream.
- Arteriography
- Ascending aortography
- Selective arteriography of supra-aortic vessels
Treatment
Indications for Revascularization
- Symptomatic ischemia of the posterior fossa
- Symptomatic subclavian steal syndrome
- Disabling upper extremity claudication
- Preservation of flow to LIMA/RIMA
- Preop coronary bypass surgery, where LIMA/RIMA will be used
- Postop CABG LIMA/RIMA with ischemia (with or without coronary-subclavian steal syndrome)
- Preservation of inflow to axillary graft or dialysis conduit
- “Blue-digit” syndrome (embolization to fingers)
- Inability to measure blood pressure
- Progressive stenosis or thromboembolus threatening cerebral blood supply
Indications for Revascularization in Asymptomatic Patients
- Angioplasty of the subclavian stenosis before other cardiovascular intervention and preservation of the vasculature for other angioplasty procedures
- Preservation of the cerebral perfusion. If other arterial lesions exist at the level of the supra-aortic vessels, to improve cerebral flow.
PTA
Percutaneous revascularization with balloon angioplasty followed by stent placement is the treatment of choice.
- Prevertebral Portion of Subclavian Artery: Balloon expandable or self expanding stents with good radial force
- Postvertebral Portion of Subclavian Artery: Self expanding stents to avoid possibility of postvertebral compression by extravascular structures at the thoracic outlet
Indications for Covered Stents
- Aneurysm or “pseudoaneurysm”
- Traumatic artery injury
- Spontaneous arterial rupture or dissection
Associated Vertebral Artery Stenosis
- Kissing balloon technique
- Complication: brain embolization
- Cerebral protection devices, protection balloons, or filters could be used.
Surgery
- Carotid-subclavian bypass
- Aortosubclavian bypass
- Axilloaxillary bypass
Technical Issues
Anticoagulation
- Premedication with Aspirin, with optional addition of clopidogrel
- Anticoagulation for a period of several weeks prior to revascularization in cases of Subclavian occlusion
Femoral Approach
It is used at first intention in the majority of the cases
Brachial Approach
- Recanalization of an occluded Subclavian artery (SA)
- When the occlusion begins at the ostium of the SA
- Severe tortuosity of the aorta
- Iliac and subclavian artery
- Bilateral occlusion of the iliac arteries
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)[1]
Management of Patients With Occlusive Disease of the Subclavian and Brachiocephalic Arteries (DO NOT EDIT)[1]
| Class III (No Benefit) |
| "1. Asymptomatic patients with asymmetrical upper-limb blood pressure, periclavicular bruit, or flow reversal in a vertebral artery caused by subclavian artery stenosis should not undergo revascularization unless the internal mammary artery is required for myocardial revascularization. (Level of Evidence: C) " |
| Class IIa |
| "1. Extra-anatomic carotid-subclavian bypass is reasonable for patients with symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis or occlusion (subclavian steal syndrome) in the absence of clinical factors predisposing to surgical morbidity or mortality. (Level of Evidence: B) " |
| "2. Percutaneous endovascular angioplasty and stenting is reasonable for patients with symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis (subclavian steal syndrome) who are at high risk of surgical complications. (Level of Evidence: C) " |
| "3. Revascularization by percutaneous angioplasty and stenting, direct arterial reconstruction, or extraanatomic bypass surgery is reasonable for patients with symptomatic ischemia involving the anterior cerebral circulation caused by common carotid or brachiocephalic artery occlusive disease. (Level of Evidence: C) " |
| "4. Revascularization by percutaneous angioplasty and stenting, direct arterial reconstruction, or extraanatomic bypass surgery is reasonable for patients with symptomatic ischemia involving upper-extremity claudication caused by subclavian or brachiocephalic arterial occlusive disease. (Level of Evidence: C) " |
| "5. Revascularization by either extra-anatomic bypass surgery or subclavian angioplasty and stenting is reasonable for asymptomatic patients with subclavian artery stenosis when the ipsilateral internal mammary artery is required as a conduit for myocardial revascularization. (Level of Evidence: C) " |
References
- ↑ 1.0 1.1 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). "2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery". Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.
- PMID 8105760
- Henry et al “Angioplasty and Stenting of the Carotid and Supra-Aortic Trunks” pg. 655-671.
- Grossmans “Catheterization” 7th Ed. pg. 573-575
- PMID 16198893