Endovascular Management versus Surgery for Proximal Subclavian Artery Lesions

doi:10.1016/j.avsg.2008.08.001

Annals of Vascular Surgery

Volume 22, Issue 6, November 2008, Pages 769-775

https://doi.org/10.1016/j.avsg.2008.08.001 Get rights and content

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Introduction

Best management of first subclavian artery (SA) segment stenotic and occlusive pathologies remains controversial. Initially, symptomatic SA lesions characterized by vertebrobasilar insufficiency (VBI) and/or upper limb ischemia have been treated via direct repair. However, transthoracic procedures have demonstrated unfavorable morbidity and mortality rates.¹ Therefore, extrathoracic approaches and extra-anatomic procedures for the reconstruction of proximal SA lesions (i.e., subclavian-to-carotid transposition [SCT], carotid-subclavian artery bypass, subclavian-to-subclavian bypass, axilloaxillary bypass) have been developed and have enjoyed increasing popularity. According to the literature, SCT, described by Parrott in 1964, is the most durable procedure with reported long-term patency rates of 90-100%.2, 3, 4, 5 Most recently, SCT has gained renewed importance in patients suffering from aneurysms of the proximal descending aorta, to create an adequate proximal landing zone for endovascular repair.6, 7 Nevertheless, for anatomical reasons, all procedures involving the SA are technically demanding, and local complications may play a detrimental role.⁸ Therefore, endovascular techniques (percutaneous transluminal angioplasty [PTA] with or without stenting) for the treatment of stenotic and occlusive SA lesions, first reported in 1980 by Bachmann and Kim,⁹ have become an increasingly popular treatment option. Larger trials comparing surgical and endovascular treatment of SA pathologies are limited. The aim of this study is a head-to-head analysis of SCT versus stent-supported PTA (sPTA) in patients with symptomatic proximal SA lesions.

Section snippets

Materials and Methods

Data were entered prospectively into a computerized vascular database and analyzed in a retrospective manner. From January 1995 to March 2007, 74 patients were treated for symptomatic SA pathologies by SCT or sPTA in a tertiary university-based care center. Both patient groups were treated by the same group of surgeons. Preferentially, an endovascular approach was chosen by the attending surgeon. Prior to the procedure, medical history was evaluated and physical examination with pulse wave

Results

From January 1995 through August 2007, 74 patients (40 females, mean age 61 years, range 39-85 years) underwent sPTA (n = 40) or primary SCT (n = 34) for symptomatic proximal SA occlusive lesions (occlusion or hemodynamic significant stenosis [>70%]). SA occlusive disease (SAOD) was of atherosclerotic origin in all cases.

Discussion

In our study we have compared two concurrently used methods to treat symptomatic central SAOD. Symptomatic SAOD is a rare entity compared to internal carotid artery stenosis. Sterpetti et al.¹² reported that SA revascularization represents only 4.6% of cases compared to the number of carotid endarterectomies. Whereas SCT has been performed since the 1960s, endovascular treatment of SAOD was first described in the 1980s.2, 9 There is an ongoing debate as to whether stent implantation into the SA

Conclusions

In conclusion, sPTA of symptomatic SAOD can be performed successfully by vascular surgeons. Long-term results are excellent when the sPTA is not enforced and performed only in straightforward cases. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions. sPTA for occlusions may be attempted, but one must encounter a 50% failure rate. Our results should be confirmed with a prospective randomized trial.

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Surgery

(1969)

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Subclavian atherectomy and angioplasty for coronary subclavian steal syndrome post CABG
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Surgical options such as carotid-subclavian bypass, carotid-to-carotid bypass, subclavian-to-subclavian bypass, subclavian-to-axillary bypass are usually reserved for patients who fail endovascular management. Only a few studies have compared percutaneous endovascular techniques to surgical revascularization and concluded that both treatments are safe and effective [13,14]. The role of endovascular subclavian atherectomy for treatment of SAS in CSSS is not clear.
Coronary subclavian steal syndrome is an uncommon complication occurring in patients with coronary artery bypass graft (CABG). We describe a case of a 69-year-old male with a remote history of CABG who presented with exertional left arm pain and angina. Computed Tomographic Angiography of the chest demonstrated a severe left proximal subclavian artery stenosis. The case demonstrates successful application of subclavian atherectomy with use of embolic protective device, alleviating the need of stent, for treatment of Coronary subclavian steal syndrome in patient with remote history of CABG.
Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review
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They concluded that both techniques are effective and safe in the short and medium term. The long-term results were assessed just for open surgery [33–38]. Simple angioplasty patency rates were between 20% and 50% in case of occlusion.
Subclavian steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal ipsilateral subclavian artery.
Four patients with subclavian steal syndrome were treated in our center. Percutaneous radial approach was used for angioplasty, primary stenting of subclavian artery was performed, surgical techniques in particular carotid-subclavian bypass and carotid-subclavian transposition were used.
We report the cases of four patients, three of which are male, with an average age of 60 years. All of them were symptomatic. Diagnosis was made by duplex ultrasound, supplemented by CT-angiography and arteriography. Endovascular treatment was attempted in all four patients, which was successful in two patients, who underwent primary stenting, and failed for the two others, for whom surgical treatment was considered. One had a subclavio-carotid bypass graft with a polytetrafluorethylene (PTFE) prosthesis and the other had a subclavio-carotid transposition. The technical results were satisfactory in all patients with symptoms resolution. The postoperative evolution was without notable complications and the postoperative checkups were satisfactory.
There are excellent screening tools and effective medical therapies which can be instituted if the SSS is diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness. Nevertheless, large, prospective, randomized and controlled trials are needed to compare the long-term patency rates between the endovascular and surgical techniques.
Endovascular and Surgical Management of Subclavian Artery Occlusive Disease: Early and Long-Term Outcomes
2020, Annals of Vascular Surgery
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Jahic et al.14 reported that ER of subclavian artery lesions was associated with a procedural success rate of 100% in case of stenosis and 55.5% in total occlusions. In addition, Linni et al.,15 in their retrospective study, reported a primary failure in 30% of patients who underwent ER, all of them being subclavian artery occlusions. On the other side, some authors comparing the results of OSR and ER in total occlusive lesions demonstrated equal effectiveness and fewer complications with endovascular therapy.6
The aim of the study was to report early and late outcomes of surgical and endovascular management of subclavian artery atherosclerotic disease (SAAD).
Data about consecutive patients treated for subclavian artery atherosclerotic occlusive disease between 2001 and 2018 either by open surgical repair (OSR) or by endovascular repair (ER) were retrospectively collected and analyzed. Primary outcomes included 30-day death, as well as cardiac and neurologic events, reported separately for occlusion and stenosis. Secondary outcomes included primary patency in the long term, reported separately for occlusive and stenotic lesions. The Kaplan–Meier analysis with the logrank test was used to estimate long-term primary patency. Chi-squared and t-tests were used as appropriate to compare the outcomes of the 2 groups. A P value < 0.05 was considered statistically significant.
Sixty-eight patients were treated using ER (49 patients) and OSR (19). Technical success rate was 100% in both groups. During in-hospital stay, 1 brachial hematoma and 2 acute upper limb ischemia occurred in the ER group and in the OSR group, respectively. At 30 days, no deaths or neurological/cardiac events were recorded in both ER and OSR groups. Symptoms resolution and upper limb salvage were 100% in both groups.
In the ER group, primary patency was 100% at 7 years in patients who had been treated for stenotic lesions and 62.5 ± 21.3% in patients who had been treated for occlusive lesions (P = 0.0035). In the OSR group, primary patency was 100% at 7 years in patients treated for stenotic lesions and 25 ± 21.6% in patients who had been treated for occlusive lesions (P < 0.0001). Overall, long-term primary patency in the OSR group was 76.9 ± 11.7% at 7 years, being lower than that reported after ER (93.4 ± 4.5%, P = 0.02).
Both ER and OSR proved to be safe, effective, and durable in the treatment of SAAD. In particular, the primary patency rates at long term for both ER and OSR showed better outcomes for stenotic lesions.
An axillary-subclavian artery aneurysm in pre-rupture revealing Marfan syndrome
2019, JMV-Journal de Medecine Vasculaire
Le syndrome de Marfan est une maladie génétique du tissu conjonctif de transmission autosomique dominante, caractérisée par un grand polymorphisme clinique et dont le pronostic dépend des complications cardiovasculaires associées, dominées par les atteintes aortiques proximales. Les anévrismes artériels périphériques sont rares au cours du syndrome de Marfan et sont exceptionnellement révélateurs de la maladie. Nous rapportons le cas d’un volumineux anévrisme de l’artère axillo-sous-clavière en pré-rupture révélant un nouveau cas de syndrome de Marfan. L’intervention chirurgicale a consisté en une mise à plat de l’anévrisme et rétablissement de la continuité artérielle par greffe veineuse ; les suites opératoires étaient simples.
Marfan syndrome is an autosomal dominant disorder of connective tissue which has many clinical symptoms and whose prognosis depends on associated cardiovascular complications, dominated by proximal aortic disorders. Peripheral arterial aneurysms are rare during Marfan syndrome and are exceptionally indicative of the disease. We report the case of a large aneurysm of the axillary-subclavian artery in pre-rupture revealing a new case of Marfan syndrome. Treatment consisted in surgical repair by resection of the aneurysm and performing a venous bypass graft; the postoperative course was uneventful.
Open versus endovascular treatment of subclavian artery atherosclerotic disease
2019, Journal of Vascular Surgery
Citation Excerpt :
Finally, all event rates in the included trials are reported on an intention-to-treat basis. Overall, seven clinical studies10-16 were included in this meta-analysis (Fig 1). In total, 731 patients with SAAD underwent 760 primary procedures (463 open and 297 endovascular procedures).
The aim of this study was to compare open and endovascular treatment of patients with subclavian artery atherosclerotic disease (SAAD) as far as early and late outcomes are concerned.
A systematic literature review conforming to established criteria was conducted to identify eligible articles published before January 2018. The following online search engines were used: PubMed, Embase, Scopus, and Cochrane Library (search conducted between December 2017 and January 2018). Eligible studies compared early and late major outcomes between open and endovascular therapy for patients suffering from SAAD.
Overall, seven clinical studies included 731 patients undergoing 760 procedures in total (297 endovascular and 463 open procedures). The majority of procedures (99.7%) referred to symptomatic patients, and more patients undergoing open surgery had an occlusion compared with patients undergoing endovascular repair, the majority of whom had a stenosis. Regarding early outcomes (30-day death, cardiac events, technical success, and central nervous system events), there was no difference between the two methods. Only peripheral nervous system complications were more prevalent in patients undergoing open repair (odds ratio [OR], 7.01; 95% confidence interval [CI], 2.142-22.921; P = .001). Regarding late outcomes, open repair was associated with significantly higher 1-year (OR, 4.33; 95% CI, 1.954-9.619; P = .0003), 3-year (OR, 5.67; 95% CI, 2.881-11.167; P < .0001), and 5-year (OR, 4.27; 95% CI, 1.906-9.567; P = .0004) primary patency rates compared with endovascular therapy. However, 5-year freedom from recurrent symptoms as well as 5-year overall survival showed no difference.
Open repair and endovascular repair in patients with SAAD do not show any difference concerning the majority of early major outcomes, although more patients undergoing open repair had an occlusion. However, open surgery seems to prevail regarding long-term primary patency, although long-term survival and freedom from recurrent symptoms show no difference.
Clinical significance of reversal of flow in the vertebral artery identified on cerebrovascular duplex ultrasound
2018, Journal of Vascular Surgery
Reversal of flow in the vertebral artery (RFVA) is an uncommon finding on cerebrovascular duplex ultrasound examination. The clinical significance of RFVA and the natural history of patients presenting with it are poorly understood. Our objective was to better characterize the symptoms and outcomes of patients presenting with RFVA.
A retrospective review was performed of all cerebrovascular duplex ultrasound studies performed at our institution between January 2010 and January 2016 (N = 2927 patients). Individuals with RFVA in one or both vertebral arteries were included in the analysis.
Seventy-four patients (74/2927 patients [2.5%]) with RFVA were identified. Half of the patients were male. Mean age at the time of the first ultrasound study demonstrating RFVA was 71 years (range, 27-92 years); 78% of patients had hypertension, 28% were diabetic, and 66% were current or former smokers. Indications for the ultrasound examination were as follows: 44% screening/asymptomatic, 7% anterior circulation symptoms, 20% posterior circulation symptoms, 28% follow-up studies after cerebrovascular intervention, and 5% upper extremity symptoms. At the time of the initial ultrasound examination, 21 patients (28%) had evidence of a prior carotid intervention (carotid endarterectomy or carotid stenting), 21 patients had evidence of moderate (50%-79%) carotid artery stenosis (CAS) in at least one carotid artery, and 12 patients (16%) had evidence of severe (>80%) CAS. Of the 15 patients presenting with posterior circulation symptoms, 11 (73%) had evidence of concomitant CAS. In contrast, 22 of the 59 patients (37%) without posterior circulation symptoms had duplex ultrasound findings of CAS (P = .01). The mean duration of follow-up was 28 ± 22 months. Follow-up data were available for 63 patients (85%), including the 15 patients who presented with posterior circulation symptoms. Of these 15 patients, 5 underwent subclavian artery revascularization, including balloon angioplasty and stenting in 4 patients and open/hybrid revascularization in 1 patient. Five individuals were awaiting intervention. Three patients underwent carotid endarterectomy for CAS, with resultant improvement in posterior circulation symptoms. Finally, one patient was deemed too high risk for intervention, and one patient was found to have an alternative cause for symptoms. The remaining 59 patients continued to be asymptomatic during follow-up. One patient progressed to vertebral artery occlusion, and six patients had progression of CAS.
Symptomatic RFVA responds well to intervention, including subclavian artery stenting and carotid intervention in patients with CAS. The majority of patients with this finding are asymptomatic at the time of presentation. Although progression of vertebral artery disease is rare, these patients may benefit from monitoring for progression of CAS with surveillance ultrasound.

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: Presented at the 18th Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, February 1-3, 2008.

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Papers presented to the Peripheral Vascular Surgical Society–Winter 2008Endovascular Management versus Surgery for Proximal Subclavian Artery Lesions

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conclusions

J Vasc Surg

Eur J Vasc Endovasc Surg

J Vasc Surg

Ann Thorac Surg

Eur J Vasc Endovasc Surg

J Vasc Surg

Am J Surg

J Vasc Surg

Ann Vasc Surg

J Vasc Interv Radiol

J Vasc Surg

Surgical treatment of occlusion of the innominate, common carotid, and subclavian arteries: a 10 year experience

Surgery

Papers presented to the Peripheral Vascular Surgical Society–Winter 2008
Endovascular Management versus Surgery for Proximal Subclavian Artery Lesions