Catheterization and Cardiovascular Interventions 86:E194–E199 (2015)

PERIPHERAL VASCULAR DISEASE Case Report Iatrogenic Subclavian Artery and Aortic Dissection with Mesenteric Ischemia following Subclavian Artery Angioplasty: Endovascular Management  n, MD, Lorenzo Azzalini,* MD, MSC, and Jean-Franc¸ois Dorval, MD Xavier Milla Subclavian stenosis affects up to 5% of patients referred for coronary artery bypass grafting. Albeit usually asymptomatic, this condition can cause myocardial ischemia due to a steal phenomenon from the distal subclavian artery when the left internal mammary artery is used as a coronary bypass. We describe a case of proximal subclavian artery angioplasty complicated with aortic dissection and subsequent lifethreatening mesenteric ischemia. For the first time, we illustrate an endovascular approach to both complications consisting in urgent stenting of the celiac trunk and the superior mesenteric artery followed by staged thoracic endovascular aortic repair due to progressive aortic dilatation. VC 2015 Wiley Periodicals, Inc. Key words: coronary-subclavian steal syndrome; subclavian stenosis; mesenteric stenting; aortic endograft

INTRODUCTION

CASE DESCRIPTION

Subclavian artery stenosis can be diagnosed in patients who present with upper limb claudication or posterior fossa ischemic symptoms due to vertebralsubclavian steal phenomenon [1]. Similarly, patients with previous ipsilateral internal mammary coronary bypass can develop symptoms of myocardial ischemia, which is known as coronary-subclavian steal syndrome [2]. Subclavian stenosis affects up to 5% of patients referred to coronary artery bypass grafting (CABG) [3]. Over the last two decades, endovascular therapy using stents has become an established therapy for subclavian artery disease, proving to be both effective and safe [4]. Although the periprocedural risk is similar to that with invasive surgical procedures [5], severe complications have been described. We report a case of left subclavian artery (LSA) percutaneous intervention complicated with iatrogenic aortic dissection. We outline a two-step endovascular management of this complication: first, an urgent transcatheter approach to mesenteric ischemia, through stenting of celiac trunk and superior mesenteric artery (SMA); and, subsequently, the elective use of thoracic endovascular aortic repair to stabilize a potentially life-threatening aortic dilatation.

A 61-year-old male with past history of hypertension and hypercholesterolemia was admitted at our institution with non ST-elevation myocardial infarction. Coronary angiography showed three-vessel disease (SYNTAX score: 23). Left ventricular ejection fraction was 25%. After Heart Team discussion, CABG was performed: left internal mammary artery (LIMA) to the left anterior descending artery, and three saphenous

C 2015 Wiley Periodicals, Inc. V

Additional Supporting Information may be found in the online version of this article.  Department of Medicine, Montreal Heart Institute, Universite al, Que bec, Canada De Montre Conflict of interest: Nothing to report. *Correspondence to: Lorenzo Azzalini, MD, MSc, Department of Medicine, Interventional Cardiology, Montreal Heart Institute, 5000 Belanger, H1T 1C8; Montreal, QC, Canada. E-mail: lorenzo.azzalini@ umontreal.ca Received 18 January 2015; Revision accepted 22 February 2015 DOI: 10.1002/ccd.25905 Published online 29 June 2015 in Wiley Online Library (wileyonlinelibrary.com)

Endovascular Management of Mesenteric Ischemia

venous grafts to the first diagonal, first marginal and posterior descending artery. The patient was discharged after an uneventful postoperative course. Three weeks later, the patient consulted for dyspnea and angina on exertion. He also complained of left arm claudication and paresthesias. Physical exam was remarkable for a cold left arm, with weak left radial pulse. A diminished systolic blood pressure in left arm was noticed (40 mmHg difference between arms). LSA stenosis with subclavian steal phenomenon was suspected. Doppler ultrasonography showed flow acceleration at the proximal LSA (300 cm/s; Fig. 1A). A contrast-enhanced computed tomography angiography (CTA) showed a severe stenosis in the proximal LSA (Fig. 1B and Supporting Information Online Fig. 1; length: 30 mm; reference diameter 10 mm distal to the stenosis: 9 mm). Patient’s symptoms were attributed to hypoperfusion of left arm and low coronary flow through the LIMA bypass. The patient was scheduled for percutaneous intervention on the LSA. The procedure was carried out from a right femoral access. A 70-mm Hg gradient was noticed across the stenosis (Fig. 1C, Supporting Information Online Video 1). After balloon dilatation at 8 atm with a 6  20-mm PowerFlex Pro balloon (Cordis Corp., Miami Lakes, FL), a self-expandable 10  40 mm SMART (Cordis Corp.) bare-metal stent (BMS) was implanted in the proximal LSA, with little ostial protrusion (2–3 mm) in the aorta (Fig. 1D). A 15-mm Hg residual gradient was documented and postdilatation (10 atm) was performed with a 10  40-mm Powerflex Pro balloon. At this point, a dissection was noticed at the distal edge of the stent, which extended distally involving the ostium of the left vertebral artery (Fig. 1E, Supporting Information Online Video 2). The dissection was immediately sealed with a second overlapping 8  30 mm SMART stent (Fig. 1F), to prevent extension into the vertebral circulation. To avoid stent malapposition at the overlap region, a final balloon postdilatation (10 atm) was performed in the proximal LSA with a 10  40-mm Powerflex Pro balloon, (Fig. 1G). Final angiography showed an optimal result, without residual pressure gradient, and normal flow in the left vertebral artery (Fig. 1H, Supporting Information Online Video 3). The patient remained asymptomatic throughout the procedure. In the following hours, the patient developed intense abdominal pain refractory to conventional analgesia, accompanied by hematochezia. Physical exam and vital signs were normal. Laboratory test were remarkable for hyperlactatemia (13 mmol/l; normal values

Iatrogenic subclavian artery and aortic dissection with mesenteric ischemia following subclavian artery angioplasty: Endovascular management.

Subclavian stenosis affects up to 5% of patients referred for coronary artery bypass grafting. Albeit usually asymptomatic, this condition can cause m...
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