Subclavian revascularization: how to handle the occluded ......Technical considerations • Access...
Transcript of Subclavian revascularization: how to handle the occluded ......Technical considerations • Access...
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Subclavian revascularization: how to handle the occluded subclavian
John H. Rundback MD
Advanced Interventional & Vascular Services LLP
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Disclosure
John H Rundback MD
.................................................................................
I have the following potential conflicts of interest to report:
Compensated Board Member – VIVA Physicians Inc.
Compensated Consultant – Medtronic, Abbott Vascular, Boston Scientific, Phillips, CSI, Cook, Intact Vascular, Eximo (now Angiodynamics), Vesper
Non-compensated Investigator – Pluristem, Intact, Bard, Medtronic, Boston Scientific, Surmodics, Micromedical
Equity – Eximo
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Clinical presentations
• Incidental
• Subclavian steal –vertebrobasilar insufficiency (vertigo, diploplia, imbalance) arm claudication, dimishedarm pulses, muscle wasting (75% left side)
• Coronary steal – post LIMA/RIMA, angina or MI
Cua J Card 2017
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Technical considerations
• Access site -- radial, femoral, both (snare/rendezvous)
• Wire type – 0.014/0.018/0.035, tip weight, hydrophilic
• BES or stent graft
• Sequential dilation
• Generally no DEP
• Don’t treat – potential vertebral
or IMA compromise, dense Ca++, uncertain wire course
• TEVAR/long lesion/subintimal →
Ahmed CV Int Rad 2016: Inc tech results, NOT patency or clinical outcomes
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Access site
Femoral
-most cases
-easier to visualize arch
-long angled sheath/guide
-occasional second control catheter for aortic imaging
** consider reactive hyperemia to promote arm flow
Radial (combined)
-no femoral access-aortoiliac dz
-type 3 arch
-fTEVAR
-occlusions
** transradial vasodilator to promote arm flow
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R vertebral
L vertebral
VERTIGO
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Able to cannulate origin from arch →favorable femoral treatment
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Catheter choices – headhunter, tapered/non-taperd angled glidecatheter, Berenstein, Kumpe
Avoid engaging
lesion with catheterNote to-and-fro
flow in vertebral
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WITH HAND
EXERCISE
Provocative maneuvers can confirm
hemodynamic significance of lesion
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Balloon expandable stent
From femoral approach prefer 0.018” or 0/035” (Rosen) wires
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CORONARY STEAL
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Radial Approach
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Trans-radial
retrograde
angiogram.
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Bates August 2019
Retrograde wire
diverts to media.
Antegrade
angiogram
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Snare wire and cross with 6 or 7 Fr sheath
Bates August 2019
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Position stent
Bates August 2019
Position
stent inside
sheath
Retract sheath
and do test
injections to
make sure
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Final
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Delay in vertebral flow reversal
Bates August 2019
.014 inch Doppler
flow wire in the
vertebral artery
4 French Catheter via left brachial
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Subclavian Artery Stenting Outcomes
Mousa. J Vasc Surg. 2015
≈ 70-90% primary
patency
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Subclavian Artery Stenting:
In-Stent-Restenosis
Mousa. J Vasc Surg. 2015
OCCLUSIONS not a restenosis risk?
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Carotid Subclavian Bypass
• Supraclavicular incision
• Prosthetic graft
• Non-traversable lesion
• Juxta-vertebral (or distal)
• Risks:– Death 1%
– Nerve injury 9%
– Lymph leak 2%
– Infection 1%
– Hematoma 1%
Cina. J Vasc Surg. 2002
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Carotid-Subclavian Bypass Outcomes
Cina. J Vasc Surg. 2002
≈ 80-90% primary
patency
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Ann Vasc Surg. 2019 Dec 18.
Endovascular And Surgical Management Of Subclavian Artery Occlusive Disease: Early And Long Term Outcomes.
Benhammamia M1, Mazzaccaro D2, Ben Mrad M1, Denguir R1, Nano G3.
Sixty-eight patients ER (49 patients) and OSR (19).
Technical success rate was 100% in both groups.
Cxs: 1 brachial hematoma (ER) and 2 acute upper limb ischemia (OSR).
Symptoms resolution and upper limb salvage were 100% in both groups.
Primary Patency @ 7 years:
(ER) 100% for stenotic lesions and 62.5%+21.3% for occlusive lesions (P=0.0035).
(OSR) 100% for stenotic lesions and 25%+21.6% occlusive lesions (P<0.0001).
Overall, combined long-term primary patency in the OSR group was 76.9%+11.7% at 7 years, and after ER (93.4%+4.5%P=0.02).
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Conclusions
• Sublavian stenoses/occlusions are uncommon but important lesions
• Treat when symptomatic
• Specific surgical and endovascular indications
• Mostly transfemoral but increasingly radial
• Diligent intervention
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Subclavian revascularization: how to handle the occluded subclavian
John H. Rundback MD
Advanced Interventional & Vascular Services LLP