Centers of Excellence in Interventional Cardiology and Radiology

Interventional radiology

Subclavian arteries angioplasty

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Only 24 hours hospitalization

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Generalities

Subclavian arteries (there are two on each side of the neck) are branches of the aorta. Subclavian artery stenosis can be a cause of significant morbidity as it can lead to ischemia (due to insufficient blood supply in the tissues) affecting the upper extremities, brain and in some cases the heart.

What are the causes of stenosis?

Atherosclerosis (fatty deposits in the walls of blood vessels) is the most common cause of this condition. The risk factors associated with atherosclerosis are hypertension, smoking, obesity, dislipidemia, diabetes.

Other etiologies include arteritis (inflammation of the artery walls, i.e. Takayasu arteritis, giant cell arteritis), inflammation due to radiation exposure, compression syndromes, fibromuscular dysplasia, and neurofibromatosis.

Frequently, patients with subclavian artery stenosis have concomitent lesions of other vessels (coronary arteries – the heart vessels, carotid arteries – the main vessels of the neck, the arteries of the legs), so the patients affected with this disease are at increased risk of developing symptomatic coronary artery disease (angina – chest pain, or heart attack) and cerebrovascular events (eg. stroke).

The left subclavian artery is more likely to be affected (3-4 times more frequently), close to its origin from the aorta.

If there is an isolated stenosis, the symptoms may lack due to the collaterals (new vessels that open and facilitate blood supply to the affected areas).

The symptoms include muscle fatigue, arm pain (claudication), rest pain and finger necrosis (blocking the blood supply of the fingers caused by pieces of the atherosclerosis plaque), bleeding in the nails.

Neurologic symptoms may occur (due to coronary-subclavian “steal”, the blood is redirected from normal vessels that originate in the subclavian artery to the affected area): visual disturbances, syncope (loss of consciousness), ataxia, vertigo, dysarthria (difficulty in speaking), ataxia (inability to maintain balance), vertigo (dizziness) and facial sensory deficits. In patients with internal mammary artery (IMA) grafts as a result of coronary artery bypass graft (CABG) surgery, the symptoms of ischemic heart disease may be recurrent.

Diagnosis:

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Subclavian artery stenosis can be suspected in case of unequal arm pulse or blood pressures (more than 20mmHg difference), abnormal bruits (murmurs) in the neck region, changes in the upper limbs (eg finger necrosis, nail hemorrhages).

Inflammation tests (blood tests: C reactive protein CRP, ESR) are necessary if an inflammatory disease is suspected (arthritis, vasculitis).

Arterial Doppler ultrasound can reveal changes that may be associated with subclavian artery stenosis; is a noninvasive method and, in addition, it is useful for posttreatment follow-up.

Other imagistic tests include:

• MRI or angioMRI

• CT or CT angiography

• Arteriography

• Aortography of the ascending aorta

• Selective arteriography of the supraaortic vessels

The treatment is medical, surgical or interventional.

The surgical treatment is bypass surgery (connection between the subclavian artery and another vessel, “skiping” the narrow part using another vessel of the body – an artery or vein; can be carotid-subclavian bypass, aortic-subclavian artery, axillary-axillary).

The interventional treatment is first intention, minimally invasive, and involves balloon angioplasty (balloon dilation of the stenosis) followed by placing a stent (a small tube that preserves the normal dimension of the vessel)

Indications

The indications for the interventional treatment are:

• Symptomatic ischemia

• Subclavian steal syndrome

• Important claudication of the arm

• In order to preserve the blood flow in the mammary artery or before the coronary artery bypass intervention using the mammary artery

• In case of ischemia after coronary artery bypass grafting (coronary-subclavian steal syndrome)

• In dialysed patients in order to preserve the dialysis catheter or in patients with axillary graft

• The “blue fingers” syndrome (finger necrosis caused by particles)

• Inability to measure the blood pressure

• Progressive stenosis or thrombi that can migrate in the cerebral circulation

• Asymptomatic patients have the indications for interventional treatment of subclavian artery stenosis if they are undergoing other cardiovascular revascularization procedures to preserve the normal blood flow to the brain or to increase it (when injuries of other vessels above the aortic arch are associated).

Procedure

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The technique is similar to angiography.

The procedure is performed under general or local anesthesia.

After anesthesia administration, a small inguinal incision to visualize the femoral artery to be punctured; we introduce a sheath (a plastic tube that allows us to handle the equipment required for the procedure).

Usually we use the femoral artery approach (as described above), but we can also perform the procedure using the brachial artery approach (puncture of the artery of the arm, incision at the fold of the elbow), or radial artery approach (incision at the wrist).

Subsequently heparin is administered (a medicine that prevents blood clotting during the procedure). A guide wire (a thin wire) and a catheter are inserted to the stenosis site. Angiography will be performed at different times to check the location of the catheters. Subsequently the stenosis is dilated with a balloon that is inflated with diluted contrast agent, followed by stenting in order to preserve the normal diameter of the vessel. Finally, the stent position is checked by arteriography (also we check for any residual stenosis or whether the stent caused the closure of the vessels that originate in the subclavian artery). All catheters are removed. Sheath may be left in place for several hours.

Is it painful?

The procedure involves general anesthesia, so the patient will not feel anything; after the intervention, medicines for pain are administered as needed (a little discomfort related to the incision is possible).

How long does it take?

The procedure time usually ranges between 1-2 hours; the procedure is performed in the cardiac catheterization laboratory.

Risks

Complications are rare and the risk of complications is low due to proper preparation and constant observation of the patient.

• Allergic reactions to the substances administered

• Reactions to anesthetics

• Arteriovenous fistula at the puncture site

• Small bleedings at the puncture site

• Fever

• Headache, migraine

• Infection

• Air embolism

• Injury of the femoral artery or aortic wall

• Thrombosis of the subclavian artery or axillary artery

• Rupture or dissection of the aorta

• Stent restenosis

• Migration of the stent

• Distal embolization (fragments form the stenosis in other vessels)

• Neurological complications: stroke, transient ischemic accident, hemiplegia (paralysis of half of the body), diplopia (double vision).

Before procedure

A preoperative consultation is necessary to establish if the stenosis is suitable for the surgical or interventional treatment. The imagistic investigations aforementioned (artery Doppler, angiography, CT / angioCT, MRI / angioMRI) are very useful.

Before the procedure, the interventional cardiologist should be informed in case of history of allergy or in case of the suspicion of pregnancy. You must mention any medicines you might take (especially antiagregants – aspirin, plavix, or anticoagulants – Sintrom) or associated disorders (diabetes mellitus, renal disease)

Blood tests are performed to check the blood coagulation, hemoglobin level, renal function and if any pathology is associated, additional tests may be required.

Admission in hospital takes place the day before the procedure. In the morning of the procedure, the patient must remain fasting (not consuming food or liquids). Before the procedure, the patient will have to shave the inguinal area bilateral. The patient will receive a consent form that he have to read and sign.

After procedure

Due to the noninvasive nature of the procedure, normally the postprocedure recovery is rapid.

After the procedure you will be kept under observation in the intensive care unit and later in your room. Bed rest for 12-24 hours is needed (avoid bending the leg to prevent complications at the puncture site). Most patients can leave the hospital after 1 day and resume their normal activity (avoid exercise for a period of time is recommended). You will receive recommendations regarding your recovery and the treatment to be followed post procedure.

Once at home the patient has to be careful in case that fever or chills, changes at the site of puncture (bleeding, haematoma – a collection of blood;! A little bruising may be normal), or any changes of the leg (changes of color, temperature or sensitivity) and neurological manifestations occur.

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The interventional treatment of balloon angioplasty and stenting of subclavian artery stenosis is a modern treatment, minimally invasive, an optimum solution, associated with a rapid recovery and a reduced hospitalization.

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