Transcript The Latest on Aortic Angiography and Intervention

Angioplasty and Stenting of
the Great Vessels
Institut fur Diagnostische und Interventionelle Radiologie
Universitat Frankfurt am Main
June 7, 2006
J. Bayne Selby, Jr., MD
Medical University of South
Carolina
History
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1964 First angioplasty report by Dotter and
Judkins
1980 First subclavian angioplasty report by
Bachman and Kim
1991 Report by Soulen for subclavian
angioplasty proximal to LIMA coronary bypass
graft
1993 First subclavian stent use reported by
Mathias
Overview
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Stenoses/occlusion in the great vessels
usually represent difficult areas to access
surgically
Results with angioplasty have been
uniformly good in stenoses
Use of stents has resulted in similar results
for complete occlusions
Role of distal embolic protection devices
unclear at this time
95% Left Subclavian Stenosis
Pre
Post
Post Aortagram
Left Subclavian Stenosis – Pre,
Post, and 6 month follow-up
Pre
Immediate Post
6 months post
Patient Selection
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As always, treatment should only be
performed in those patients who have
both a hemodynamically significant lesion
and appropriate corresponding symptoms
Anatomic Locations
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Left Subclavian (most common)
Brachiocephalic
Left Common Carotid Origin
Right Subclavian (often in aberrant vessel)
Indications
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Upper Extremity Ischemia
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Cerebral Ischemia
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Arm Claudication
Emboli from lesion to hand
Anterior (carotid) symptoms
Vertebro-basilar Insufficiency w/wo subclavian steal
Diminished Inflow to Graft
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Angina in patient with LIMA
Claudication in patient with Ax-fem
Diagnosis
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Clinical History
BLOOD PRESSURES in both arms – simple
MRA
CTA
Conventional Angiography – AP and LAO
Diagnostic Angiography
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Evaluate for central lesion (stenosis/occlusion)
Evaluate for evidence of distal emboli (then do
echocardiography of heart)
Evaluate for vasospastic disorder, e.g., Raynaud’s
(do angio before and after vasodilator)
Evaluate for thoracic outlet syndrome (do
abduction and adduction angio)
Great Vessel Angioplasty/Stent
Technique
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Do baseline neurological exam
Initial high quality diagnostic thoracic aortagram
Arteriography of distal vascular beds as allowed
by degree of disease
First attempt to cross lesion from below
Use brachial approach if necessary
Give Heparin once lesion has been crossed
(2,000-3,000 units)
Great Vessel Angioplasty/Stent
Technique
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Have nurse perform neurological tests on patients at
regular intervals (e.g., speak, grip strength, smile, wiggle
toes)
Use guiding catheter or sheath
Try to use appropriate ballon size for initial dilatation, but
pre-dilate if lesion is too tight to get across
Leave balloon up for 10 seconds
Stent for >30% residual stenosis, dissection, recoil
Consider primary stent based on appearance of lesion
Brachiocephalic (Innominate)
Artery Angioplasty
99% stenosis at origin
of brachiocephalic artery
Cross lesion from an
axillary approach
Brachiocephalic (Innominate)
Artery Angioplasty
10 mm balloon with “waist”
10 mm balloon fully inflated
Brachiocephalic (Innominate)
Artery Angioplasty
Initial 99% stenosis
Final with residual stenosis <30%
Note post stenotic dilatation
Subclavian Stenosis proximal to
LIMA coronary graft – no stent
Diffuse stenosis – poor filling
of the LIMA graft
S/P Angioplasty – circa 1991
Stenosis in Single supra-aortic
Vessel – Now What?
Follow up – MR? CT? Angio?
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Peloschek P., et al. The Role of Multi-slice
Spiral CT Angiography in Patient
Management After Endovascular Therapy.
Cardiovascular and Interventional
Radiology, In Press
Subclavian Stenosis proximal to
LIMA coronary graft – with stent
Stenosis within stent
Bifurcation Lesions
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Can occur at right subclavian – right
common carotid bifurcation
Must use RAO projection to evaluate
stenosis
Options include:
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1)
2)
3)
4)
simple angioplasty
kissing balloon angioplasty
simple stent
kissing stents
Bifurcation Lesions
95% stenosis in proximal
right subclavian artery
Subclavian Steal
Bifurcation Lesions
Kissing balloon from femoral and
right axillary approach
Final Result
Excellent is the Enemy of Good!
Bifurcation Lesion
Pulse Volume Recordings
Fingers of Right Hand
Right Arm
Left Arm
Life Table Analysis
30 Subclavian Angioplasty Patients
University of Virginia
Summary of Largest Series of PTA of
Brachiocephalic Arterial Stenoses
Authors
No. of Lesions
Technical
Success
Clinical Success
Complications –
Neurologic
Complications Other
Months Followup (mean)
Selby et al
32
32/32 (100%)
31/32 (97%)
0
2
4-88 (36)
Kachel et al
47
47/47 (100%)
45/47 (96%)
0
2
3-109 (58)
Hebrang et al
43
40/43 (93%)
34/43 (79%)
0
0
6-48 (29)
Dorros et al
22
22/22 (100%)
21/22 (95%)
0
2
2-73 (28)
Motarjeme et al
16
16/16 (100%)
16/16 (100%)
0
0
8-60 (27)
Vitek et al
35
35/35 (100%)
-
0
0
-
Burke et al
29
26/29 (90%)
-
1
1
(37)
Insall et al
34
34/34 (100%)
30/34 (89%)
1
2
2-90 (26)
Romanowshi et
al
25
23/25 (92%)
17/25 (68%)
0
0
8-111 (50)
Erbstein et al
21
18/21 (86%)
17/21 (81%)
-
-
18-26
Millaire et al
46
45/46 (98%)
37/44 (84%)
1
4
9-101 (41)
Wilms et al
23
21/23 (91%)
18/21 (86%)
1
2
6-60 (25)
Farina et al
23
21/23 (91%)
(54%)
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1
(30)
OVERALL
396
380/396
(96%)
239/305
(78%)
4
16
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Summary of Series of Brachiocephalic
Arterial Occlusions
Authors
No. of Occlusions
Technical Success
Clinical Success
No. of Patients
Receiving Stents
Kachel et al
7
1/7 (15%)
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0
Hebrang et al
9
5/9 (56%)
-
0
Dorros et al
11
11/11 (100%)
-
0
Motarjeme et al
7
1/7 (15%)
1/1 (100%)
0
Mathias et al
46
38/46 (83%)
32/38 (84%)
7
Duber et al
8
7/8 (88%)
3/7 (43%)
7
Bates
5
5/5 (100/5)
-
5
Overall
93
68/93 (73%)
36/46 (78%)
19
Complications
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Puncture site complications, femoral or
brachial
Rupture of vessel
Emboli from angioplasty site
Stent misplacement
Complications
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Mathias, et al: 38 patients with total
occlusions – No significant embolic
occlusions
Complications
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Literature review by Kachel, et al:
774 supraaortic lesions treated with PTA
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0.5% Major complications
3.5% Minor complications
Explanations
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20 second delay in restoration of antegrade flow
in vertebral artery following angioplasty –
Ringelstein, et al, Nuclear Medicine data
Lack of clinical significance of small emboli to
hand
Possible different response of large vessels to
angioplasty/stent (iliac vs. SFA emboli
experience)
Still, now we have protection
devices …
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Landing zone for protection device in
supra-aortic angioplasty is often vessel too
large
Probably should use it when possible
We’re not done yet!
Articles to be published in 2006
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6 articles on results of simple angioplasty
and/or stenting of great vessels
3 articles on great vessel disease
treatment in conjunction with thoracic
aortic stent graft
2 articles on percutaneous treatment for
arteritis
Conclusion
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Angioplasty, with or without stenting is highly
effective for stenoses of the great vessels
Occlusive disease in the great vessels should
always be treated with stent
Long term result are excellent (70-90%), but
follow –up with CTA upon return of symptoms
may be necessary
Consider the use of distal embolic protection,
although rate of complications has been low
without it
Summary
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Angioplasty of the Great Vessels can be a useful
treatment in a surgically difficult area
Results mimic those of the common iliac arteries
(>90% success) and have further improved with
the use of stents, particularly for occlusions
Improvements in technology have increased the
technical success in occlusions
Complications are low, but remain a hazard –
consideration should be given to the use of
distal protection devices when anatomy is
suitable