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C H A P T E R 4
SubclavianArteryStenosis/Interventions
AtulSinglaMD,ImaadRazzaqueMD,ChiranjivS.VirkMD
I.Introduction
II.SubclavianArteryLesions
A.Asymptomatic
B.Symptomatic
III.Evaluation
IV.Angiography
A.InvasiveDigitalSubtractionAngiography
B.ArchAortography
C.SubclavianorInnominateAngiography
V.Treatment
VI.Intervention
A.DosageandProcedures
B.Follow-Up
VII.SubclavianTotalOcclusions
A.BrachialApproach
B.CombinedAntegrade(Radial)andRetrograde(CommonFemoralAccess)Approach
VIII.Outcomes
KeyPoints
■Subclavianstenosisisfourtimesmorecommonintheleftsubclavianincomparisontothe
right.
■Symptoms of subclavian stenosis include upper limb claudication, vertebrobasilar steal,
and,incaseofmammaryarterygrafttocoronaryarteries,symptomsofcoronaryischemiaand
cardiomyopathy.
■Endovascularrevascularizationisundertakenbyfemoral,brachial,orradialaccess.
■Balloonexpandablestentswithintravascularultrasound(IVUS)guidanceisrecommended
forproximallesions.
■5yearpatencyratesofsubclavianstentplacementhavebeenshowedtobegreaterthan80%
indifferentseries.
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I.Introduction
Subclavianarterystenosisisuncommonbutisassociatedwithsignificantmorbidityandmortality.
1,2
Itis
usuallyfocal,andtheleftsideisfourtimesmorecommonlyaffectedthanrightinthemajorityoflesions.
3–5
It is most frequently due to atherosclerosis but may also be caused by fibromuscular dysplasia,
Takayasuarteritis,thoracicoutletcompression,radiationinduced,ortrauma.
Anatomically, theleftsubclavianarteryoriginates asthe most distalbranchofthe aortic archwhereas
right subclavian artery is a branch of brachiocephalic artery. The subclavian artery gives rise to the
vertebral artery, the internal mammary artery, and the thyrocervical trunk, before terminating as the
axillaryartery(Fig.4.1).
FIGURE4.1 Anatomyofsubclavianartery.
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FIGURE4.2 Subclavianarterystenosisdepictingreversalofflowacrossleftvertebralarterydepictingsteal
physiology.
FIGURE4.3 ArchAortographyperformedutilizingnon-angledpigtailcatheter.
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FIGURE4.4 Selectivesubclavianangiography.
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FIGURE4.5 A,A0.014″workhorsewireacrossthelesionintotheaxillaryartery.B,JR4catheterorangledglide
catheterisadvancedoverthewireacrossthelesionandthroughthiscatheterthewireisexchangedoutforastiffer
wireeg,rosenorstiffglidewire.C,6Fr90cmshuttlesheathadvancedoverthecatheterbeyondthelesion.D,
Predilatationballooncatheteratthelesionsite,followedbywithdrawingthesheathbelowthelesion(unsheathing
thecatheter).E,Afterperformingballoondilatation,sheathisadvancedoverthedeflatingballoonacrossthelesion.
F,Stentispositionedatthelesionsiteandsheathwithdrawnwith1-2mmofstenthangingoutintheaorticarch
(unsheathingthestent).G,Stentdeployment.
II.SubclavianArteryLesions
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A.Asymptomatic
Patientswithisolatedsubclavianarterylesionsareoftenasymptomaticbecauseofthepresenceofarich
collateralsupply.
B.Symptomatic
1.Upperlimbischemia/armclaudicationandfatigue.
2. Subclavianstealsyndrome: Owing tosevere proximal obstruction,blood flow reverses along the
vertebralarterytosupplytherespectivearm(vertebral-subclaviansteal)resultingindisorientation,loss
of balance, dizziness, diplopia, nystagmus, tinnitus, or hearing loss, consistent with vertebrobasilar
insufficiency.
3. Coronary steal phenomenon: Severe proximal stenosis can also cause reversal of flow in the
coronaryarterybypassgraft(eitherleftorrightinternalmammillaryartery)tosupplythearmleadingto
angina,myocardialinfarction,andischemiccardiomyopathyifthedegreeofstealissignificant(Fig.4.2).
III.Evaluation
A.Clinical evaluationofsuspectedsignificant subclavianarterystenosisshould beginwith measuring
bloodpressureofbotharms.Adifference>15mmHgsuggestssignificantstenosis.
6,7
Thismaynothold
trueinthepresenceofbilateraldisease,which,fortunately,isaninfrequentfinding.
B.Decreasedamplitudeofthepulse,atrophicchangeswiththeskinand/ornailsoftheaffectedarm,and
auscultationofabruitinthesupraclavicularfossasuggestsubclavianarterystenosis.
C. Noninvasive imaging such as duplex ultrasound with color flow can provide anatomical and
functionalassessmentofasignificantsubclavianstenoticlesion.Findingssuchaswaveformdampening,
monophasicwaveform,flowreversal,coloraliasingsuggestiveofturbulentflow,orincreasedvelocities
atthesuspectedsiteofstenosisaresuggestiveofsignificantobstruction.
D.Othernoninvasive imagingmodalities include magnetic resonance angiogram (MRA) and computer
tomographic angiography (CTA), the latter providing excellent resolution of the lesion as well as
surroundingstructures,helpfulinplanningendovasculartreatment.
IV.Angiography
A.InvasiveDigitalSubtractionAngiography
Invasive digital subtraction angiography remains the gold standard imaging modality for assessing
significantsubclavianarterystenosis.Technique:Fordiagnosticangiographymostcommonly,common
femoralarteryaccessisutilized.Ipsilateralbrachialorradialcanbeaccessedifnecessary(eg,aortoiliac
occlusions).Introducersheathsbetween4Frand6Frsheathcanbeused.
B.ArchAortography
Archaortographyisperformedutilizingnonangledpigtailcatheterpositionedintheascendingaortainleft
anterioroblique(LAO)30-45°projection(Fig.4.3).Usuallypowerinjectionwith15-20mL/sforatotal
of30-40mLcontrastcanbeuseddependingonrenalfunctionofthepatient.Wecommonlydilutecontrast
with50%contrastand50%heparinizedsalinetoreducethetotalcontrastvolume.
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C.SubclavianorInnominateAngiography
1.Selectivesubclavianorinnominateangiographycanbeperformedusingoneoftheseveralcatheters
available(Judkinsright(JR)4,angledglide,multipurpose,vertebral,Simmons,Vitek,IMetc.[Fig.4.4]).
WecommonlyusetheJR4catheter.Thecatheterisadvancedovera0.035″ glidewireadvancedtothe
distal subclavian artery to obtain a selective angiogram. Care should be taken when engaging or
manipulatingcatheterstoavoiddislodgementofaorticatheromatominimizetheriskofstroke.Incases
when thoracic outlet syndrome is suspected, angiograms are repeated with the arm abducted and
internallyrotated.
2.Anteroposterior(AP)andipsilateralobliqueprojectionsareutilizedtoassesstheoriginoftheartery
anditscorrelationwiththevertebralandinternalmammaryartery.
3.Oncesignificantstenosisissuspectedangiographically,apullbackpressuregradientismeasuredwith
a 4Fr or 5 Fr catheter.Ideally thegradient is measuredbyrecording simultaneous pressure readings
proximalanddistaltothestenosisusingtwodifferentpressuremanifolds.Agradientof20-30mmHgis
consideredsignificant.
V.Treatment
A.Patientswithasymptomaticstenosis(eitheridentifiedincidentallyorbyimaging)haveincreasedrisk
ofmorbidity/mortality andbenefit frommedical therapyincludingaspirin, beta blockade,angiotensinconvertingenzymeinhibitor,andstatin.
5
B. Indications for revascularization include arm ischemia, vertebral-subclavian steal syndrome,
coronary-subclavianstealsyndrome,andplanned coronary bypasssurgeryusingtheipsilateral internal
mammaryartery.
8
C. Revascularization can be achieved surgically (axillary-axillarybypass, carotid-subclavian bypass,
andtranspositionofthesubclavianartery)orpercutaneously.Incurrentera,endovasculartreatmentwith
stentinghasbecomethepreferredoptionwithanacceptablerateofrestenosis.
VI.Intervention
A.DosageandProcedures
1. All patients should receive full-dose aspirin and loading dose of Plavix 24-48 hours before
intervention.70-80unitsperkilogramofunfractionatedheparinisadministeredwithadditionalheparin
bolusesprovidedtomaintainanactivatedclottingtimerange of250-300 seconds.Otherantithrombotic
regimens(BivalirudinandGPIIb/IIIainhibitors)canbeextrapolatedfromcoronaryangioplastyliterature,
buttherearenodatatovalidatetheiruseinsubclavianangioplasty.
2.Onaverage,thesubclavianarterydiameterrangesfrom7to10mmindiameter.Thebrachiocephalic
arterydiameters onaverageare 8-11 mmin diameter.For thisreason,a 7-8Fr guidecatheter or6 Fr
90cmguidingsheath(Cookshuttlesheath,BloomingtonIN)isreasonabletousetoallowforballoonand
stentcatheterstobedeliveredatthesiteofthelesion.Fornonocclusivestenoticdiseaseandsimplicity,
the preferred strategy is femoral approach (unless there is abdominal aortic disease that hinders
advancingequipment).
Initially,asmallersizediagnosticcatheter(usually5FrJR4ormultipurpose)istelescopedthroughthe
sheathandusedto engagetheostium of theleft subclavianarteryorbrachiocephalic artery. Asupport
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