Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 93-96

Endovascular revascularization of subclavian artery occlusion: Case report and review of endovascular techniques


Department of Neurosurgery, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China

Date of Submission06-Dec-2021
Date of Acceptance17-Dec-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Song Guangfu
Department of Neurosurgery, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_129_21

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  Abstract 


Subclavian artery (SCA) disease is caused by stenosis or occlusion of the proximal segment of the SCA, resulting in a retrograde blood flow of the ipsilateral vertebral artery. It is rare, with a prevalence of 0.6% to 6.4% in the general population. The common cause of this disease is atherosclerosis, followed by Takayasu's arteritis. The endovascular approach is currently the first treatment option; the success rate of this approach achieved 100% reported by many authors in the case of SCA stenosis. However, the success rate of this approach is lower in the case of SCA total occlusion, and the main reason is the inability of the wire to cross the lesion. The emergent novel endovascular techniques are trying to provide an effective solution. Recently, novel endovascular methods were successfully performed and reported in the literature. Nevertheless, a small sample size limited these studies; therefore, large-scale prospective studies are needed to ascertain their feasibility, effectiveness, and safety. In this present study, we report a successful stent-assisted angioplasty and review of endovascular techniques for the SCA total occlusion.

Keywords: Embolic protection, endovascular approach, percutaneous transluminal angioplasty, stent, subclavian artery occlusion, subclavian steal syndrome


How to cite this article:
Roufai HM, Jun Y, Guangfu S, FuYi Y, Guiliang A. Endovascular revascularization of subclavian artery occlusion: Case report and review of endovascular techniques. Indian J Vasc Endovasc Surg 2022;9:93-6

How to cite this URL:
Roufai HM, Jun Y, Guangfu S, FuYi Y, Guiliang A. Endovascular revascularization of subclavian artery occlusion: Case report and review of endovascular techniques. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:93-6. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/93/340499




  Introduction Top


Subclavian artery (SCA) disease is very uncommon, the prevalence count around 0.6% to 6.4% in the general population but can be a cause of notable morbidity.[1],[2],[3] It is caused by stenosis or occlusion of the proximal segment of the SCA, resulting in a retrograde blood flow of the ipsilateral vertebral artery.[1],[4] Clinically, the symptoms can be for the vertebrobasilar insufficiency as dizziness, syncope, ischemic event in the vertebrobasilar territory, or for the upper extremity as arm claudication, coolness, and blood pressure differential (>15 mmHg) between the arms, decrease the amplitude of pulse or even upper extremity ischemia. In many cases, this pathology can remain asymptomatic.[2],[5]

The common cause of SCA disease is atherosclerosis, followed by Takayasu's arteritis.[6],[7] The SCA and brachiocephalic artery are the predilection locations of atherosclerosis for the upper part of the body. Additional possible causes are thoracic outlet syndrome, stenosis after surgical repair of aortic coarctation or tetralogy of Fallot, and congenital abnormalities.[2],[5],[8]

SCA disease can be treated by open surgery or by an endovascular approach. Surgical recanalization consists of carotid-subclavian bypass, carotid-subclavian transposition, or axillo-axillary bypass. This approach remained for a long time the traditional approach of SCA stenosis or occlusion therapeutical method. However, recently endovascular neurosurgery achieved implement progress, and it is currently considered as the first-line approach for symptomatic SCA stenosis or occlusion.[2],[5],[9] Furthermore, the endovascular approach is minimally invasive and has a lower risk of perioperative complication.[2],[5] Many authors reported a procedural success of 100% in the case of subclavian stenosis. However, the technical success rate of the occluded SCA is still lower compared to that of the stenotic. Crossing the occluded lesion during the procedure is the main reason for the lower success rate of occlusive SCA and remains a big challenge of endovascular treatment.[10],[11]

The emergent endovascular techniques aim to provide effective and safe solutions for the treatment of total occlusion of the SCA.

In this study, we report a case of successful stent-assisted angioplasty and review the of endovascular revascularization techniques for total occlusion of the SCA.


  Case Description Top


A 54-year-old female patient with a smoking history (20 pack-year) stopped nearly 9 months ago, her medical history included hypertension and diabetes both discovered almost 10 years ago medicated, respectively, with Irbesartan and intermediate-acting insulin (18 units in the daytime and 20 units at night) and heart stenting operation less than a year ago. She was admitted to our department for dizziness and numbness of the left upper limb for 10 days. The physical examination revealed the left upper limb was cold and pulseless. The left-arm blood pressure was 88/67 mmHg, whereas the right arm blood pressure was 140/78 mmHg, a difference of 52 mmHg in systolic blood pressure. Duplex ultrasonography of the left upper limb showed that the blood flow in the left SCA was retrograde, the flow velocity in the brachial, radial, and the ulnar arteries is slightly lower and the frequency spectrum is round. The finding indicates a subclavian steal syndrome. The digital subtraction angiography was performed and showed the occlusion of the proximal segment of the left SCA, and the right vertebral artery compensates to the left SCA through the ipsilateral vertebral artery. Incidentally, the angiogram showed up moderate stenosis located on the initial segment of the right internal carotid artery, and severe stenosis of the initial segment of the right vertebral artery [Figure 1].
Figure 1: Digital subtraction angiography. (a) Demonstrate a retrograde flow down the left vertebral artery producing subclavian steal. (b) Angiogram shown a total occlusion of the left subclavian artery. (c) The stenosis of the right vertebral artery. (d) Stenosis of the right internal carotid artery3

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The laboratory examinations were within normal limits. A multidisciplinary team advises proceeding with the endovascular treatment of the left SCA occlusion. The patient's relatives were counseled for the procedure; the risks associated with it were informed, and written consent was obtained.

Endovascular procedure

The procedure was then performed under local anesthesia, conscious sedation was offered, and vital signs were monitored throughout the intervention. The patient was in a supine position on the operating table. The Seldinger technique was used to have access to the right femoral artery. An 8F guiding catheter was advanced smoothly into the ostium of the left subclavian artery. An Avigo microguidewire crossed the lesion through a found luminal microchannel at the beginning of the occlusion. A Rebar-18 microcatheter was navigated over an Avigo microguidewire distal to the occlusion site. The angiography confirmed the position of the microcatheter in the distal segment of the left SCA. The Avigo guidewire was then exchanged by the 300 cm microguidewire. The NC Treck balloon (3.25 mm × 12 mm) was sent throughout the 300 cm microguidewire into the occlusion site. The balloon was slowly expanded at 12 atm pressure. The angiography confirmed the improvement of the stenosis. A Dynamic balloon-expandable stent (8 mm × 38 mm) was sent and successfully deployed. A final check angiogram was then performed. The access site was closed using closure devices. Complete revascularization was achieved with no procedural complications. All the intervention steps are shown in [Figure 2].
Figure 2: The endovascular treatment steps. (a) Shown the guide wire intralumenal position after crossed the occlusion. (b) Balloon angioplasty of the subclavian artery. (c) Control angiogram after angioplasty. (d) Angiogram demonstrates the balloon expandable stent position before stent deployment. (e and f) The stent deployment and anterograde blood flow in the left vertebral arter 4

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One day after postoperation, the left upper limb pulse was palpable at the wrist, and the blood pressure difference between the two arms was considerably improved. The patient was discharged three days after the intervention with dual antiplatelet medication (clopidogrel 75 mg/day and acetylsalicylic acid 75 mg/day). After 1 month, Duplex ultrasonography was planned for control.


  Discussion Top


The first angioplasty for SCA stenosis was reported in 1980.[8],[9] The continuous improvement of the technical approaches, and innovative equipment allows the endovascular approach to attain almost the same outcomes as open surgery.[12] In addition, this approach has lower perioperative complications and is minimally invasive.[11] Nowadays, percutaneous transluminal angioplasty (PTA) with a stent is the first-line treatment option for symptomatic SCA stenosis.[2],[10],[13] Many authors reported a technical success rate of 100%, especially for stenotic SCA; that is not the case for total occlusion with often a lower technical success rate rather than stenosis SCA. Jahic et al. reported an initial procedural success rate of 100% in stenotic lesions against 55.5% in occlusion lesions.[11] Higashimori et al. used a combined approache (transfemoral and transbrachial) to treat by PTA with stenting 59 patients of which 76.6% were stentic and 23,3% were occlusive SCL. They achieved a technical success rate of 100% and 71.4% for stenotic and occlusive lesions, respectively, and showed a good long-term with a primary patency rate of 94.9%, 90.8%, and 85.8% at 1, 3, and 5 years, respectively.[14] Soga et al. enrolled 553 patients with subclavian disease in a large-scale multicenter in Japan to investigate the perioperative and long-term outcomes of endovascular treatment. The results are closely similar to those of Higashimori et al., with a technical success rate of 100% for stenoses, and primary patency was 90,6%, 84,4%, and 80,5% at 1, 3, and 5 years, respectively. However, the procedural success rate for total occlusion (91%) is higher than that of Higashimori.[15]

In this study, the lesion was left sided and completely occlusive. The access was achieved through a single transfemoral approach. The Avigo™ hydrophilic guidewire (0.014 inches) was used to cross the lesion. The highlight of the procedural success was first to find a lumenal microchannel at the occluded lesion and use a wire with a buckling strength tip to cross. The procedure was successful, with no perioperation complication was encountered. The symptoms relief immediately after procedural. The radial pulse was palpable. Many authors reported a lower success rate in the case of total SCA occlusion and mainly due to the failure of crossing the occluded lesion.[10],[11],[14],[16] Babic et al. in 2011 evaluate the initial and long-term endovascular therapy of SCA for chronic total occlusion, reported a success rate of (82,1%) and failed in (17,9%).[17] Liu et al. in 2016 explored the clinical effectiveness of endovascular treatment in patients with total SCA occlusion. The result showed a procedural success rate of 77.6%, and it is failed for 15 patients.[18] It should be pointed out that the success rate remains higher than previously reported, and the main reason is the use of the bidirectional (anterograde and retrograde) approach. In our case, a single femoral approach was used, and the lesion was successfully crossed. The device selection and the operator experience are factors to take into account. The combined anterograde and retrograde approach has the advantage to make another attempt to cross the lesion from transbrachial when it is failed by transfemoral approach, which increases the success rate; moreover, it can allow having the length of the lesion extend by simultaneous angiography from both accesses and to have accurate control of vertebral artery during the stenting.[18] However, this approach is not always successful; the standard wires could not bypass the lesions in either direction; therefore, another method to pass through the lesion through the subintimal plane called subintimal dissection or recanalization was introduced.[19]

The subintimal recanalization has been previously reported in the lower extremities and the cardiac literature for chronic total occlusion. This approach was recently used also for SCL total occlusion. Satti et al. in 2016 report a successful retrograde transradial subintimal approach using a heavy tip microwire. They achieved complete revascularization with no major complications.[19] However, this technique failed in 10%–15% in the lower limb arteries recanalization report, and the main reason was the inability to re-entry the wire in the true lumen after crossing the lesion.[3] This situation was encountered during the procedure of revascularization for SCA occlusion. The re-entry devices offer a suitable solution and allow to increase the success rate of the subintimal approach. Thomas et al. reported a successful case series of SCA total occlusion, where they use the OUTBACK catheter to facilitate the re-entry of the wire in the true lumen.[3] Even though this method is feasible and safe as previously reported in the lower extremities and the cardiac literature, many prospective studies are needed to evaluate his feasibility, effectiveness, and safety for total occlusion of SCA.

The novel endovascular techniques have greatly improved the procedural success rate; however, some uncommon complications have been observed especially for subclavian total occlusion.[13],[19] The most major complications are the ischemic embolic cerebral accident and upper extremity distal embolization.[20] Liu et al. reported a 6% of complication rate, and in patients for whom embolic protection was used no complication was observed.[18] Alkhouli et al. reported a case of acute hand ischemia caused by distal embolization during balloon angioplasty and stenting of the left SCA.[20] The embolic protection devices are more necessary than ever to overcome these complications. Yamamoto et al. in 2017 reported a case of subclavian total occlusion where they used an optimo balloon catheter and pull through technique to avoid the embolic event. The optimo balloon catheter (Tokai Medical Products, Japan) was placed in the SCA proximal to the origin of the vertebral artery through transbrachial access and can simultaneously protect the vertebral artery and brachial artery against distal embolism.[21] Fakih et al. in 2020 used a Scepter XC balloon to protect the vertebral artery from distal embolism during stent-assisted PTA for patients with subclavian steal syndrome. A Scepter XC balloon (Scepter XC, Microvention, Inc., Tustin, CA, USA) was placed through a transradial catheter in the ipsilateral vertebral artery, the procedure was successful without complication.[4] Even though these techniques are feasible and safety as reported above, a large-scale study is needed to evaluate any beneficial effect of these embolic protection devices during SCA revascularization.


  Conclusion Top


The emergent novel endovascular techniques have improved the procedural success rate and allow to prevent the related complications during revascularization for subclavian total occlusion; however, large-scale studies are needed to confirm their feasibility, safety, and effectiveness.

Patient consent

Informed consent has been obtained from the patient for publication of the case report and accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
El Bhali H, Bounssir A, Bakkali T, Jdar A, El Khloufi S, Lekehal B. Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review. Int J Surg Case Rep 2021;85:106173.  Back to cited text no. 1
    
2.
Osiro S, Zurada A, Gielecki J, Shoja MM, Tubbs RS, Loukas M. A review of subclavian steal syndrome with clinical correlation. Med Sci Monit 2012;18:A57-63.  Back to cited text no. 2
    
3.
Thomas WR, Chick C, Goyal N. Use of a re-entry device in left subclavian occlusion: Case series. Cardiovasc Intervent Radiol 2018;41:177-81.  Back to cited text no. 3
    
4.
Fakih R, Dandapat S, Mendez-Ruiz A, Mendez AA, Farooqui M, Zevallos C, et al. Combined transradial and transfemoral approach with ostial vertebral balloon protection for the treatment of patients with subclavian steal syndrome. Front Neurol 2020;11:576383.  Back to cited text no. 4
    
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Salman R, Hornsby J, Wright LJ, Elsaid T, Timmons G, Mudawi A, et al. Treatment of subclavian artery stenosis: A case series. Int J Surg Case Rep 2016;19:69-74.  Back to cited text no. 5
    
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Sahsamanis G, Vourliotakis G, Pirgakis K, Lekkas A, Kantounakis I, Terzoglou A, et al. Primary stenting of right-sided subclavian artery stenosis presenting as subclavian steal syndrome: Report of 3 cases and literature review. Ann Vasc Surg 2018;48:254.e1-5.  Back to cited text no. 6
    
7.
Wrotniak L, Kabłak-Ziembicka A, Rosławiecka A, Musiałek P, Bogacki P, Trystuła M, et al. Resolution of ischemic symptoms after percutaneous angioplasty for a symptomatic subclavian artery stenosis. J Vasc Surg 2016;64:684-91.  Back to cited text no. 7
    
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Verma A, Reilly JP, White CJ. Management of subclavian artery in-stent restenosis. Vasc Med 2013;18:350-3.  Back to cited text no. 8
    
9.
Maciejewski DR, Tekieli Ł, Machnik R, Kabłak-Ziembicka A, Przewłocki T, Paluszek P, et al. Simultaneous vertebral and subclavian artery stenting. Postepy Kardiol Interwencyjnej 2017;13:142-9.  Back to cited text no. 9
    
10.
Goel PK, Moorthy N. Use of subclavian steal in treating chronic total subclavian artery occlusion. Asian Cardiovasc Thorac Ann 2013;21:599-601.  Back to cited text no. 10
    
11.
Jahic E, Avdagic H, Iveljic I, Krdzalic A. Percutaneous transluminal angioplasty of subclavian artery lesions. Med Arch Sarajevo Bosnia Herzeg 2019;73:28-31.  Back to cited text no. 11
    
12.
Mufty H, Janssen A, Schepers S. Dealing with symptomatic stenosis of the subclavian artery: Open or endovascular approach? A case report. Int J Surg Case Rep 2014;5:441-3.  Back to cited text no. 12
    
13.
Ahmed AT, Mohammed K, Chehab M, Brinjikji W, Murad MH, Cloft H, et al. Comparing percutaneous transluminal angioplasty and stent placement for treatment of subclavian arterial occlusive disease: A systematic review and meta-analysis. Cardiovasc Intervent Radiol 2016;39:652-67.  Back to cited text no. 13
    
14.
Higashimori A, Morioka N, Shiotani S, Fujihara M, Fukuda K, Yokoi Y. Long-term results of primary stenting for subclavian artery disease. Catheter Cardiovasc Interv 2013;82:696-700.  Back to cited text no. 14
    
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Soga Y, Tomoi Y, Fujihara M, Okazaki S, Yamauchi Y, Shintani Y, et al. Perioperative and long-term outcomes of endovascular treatment for subclavian artery disease from a large multicenter registry. J Endovasc Ther 2015;22:626-33.  Back to cited text no. 15
    
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Dayama A, Riesenman PJ, Cheek RA, Kasirajan K. Endovascular management of aortic arch vessel occlusion: Successful revascularization of innominate and left subclavian arteries. Vasc Endovascular Surg 2012;46:273-6.  Back to cited text no. 16
    
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Babic S, Sagic D, Radak D, Antonic Z, Otasevic P, Kovacevic V, et al. Initial and long-term results of endovascular therapy for chronic total occlusion of the subclavian artery. Cardiovasc Intervent Radiol 2012;35:255-62.  Back to cited text no. 17
    
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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;35:189-96.  Back to cited text no. 18
    
19.
Satti SR, Golwala SN, Vance AZ, Tuerff SN. Subclavian steal: Endovascular treatment of total occlusions of the subclavian artery using a retrograde transradial subintimal approach. Interv Neuroradiol 2016;22:340-8.  Back to cited text no. 19
    
20.
Alkhouli M, Porter J, Waits B, Ling FS, Narins CR. Distal embolization during percutaneous subclavian artery intervention. Vasc Endovascular Surg 2016;50:175-9.  Back to cited text no. 20
    
21.
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. World Neurosurg 2017;100:709.e5-9.  Back to cited text no. 21
    


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