Annals of the Royal College of Surgeons of England (1991) vol. 73, 46-52

Percutaneous transluminal angioplasty the subclavian artery Anthony A Nicholson

William G Sheridan

MB ChB FRCR*

Radiology Senior Registrar

Surgical Senior Registrar

Nuala M Kennan MB ChB MRCPI Radiology Senior Registrar

Consultant Radiologist

Michael S Ruttley

of

MCh FRCSI

FRCP FRCR

Departments of Radiology and Surgery, University Hospital of Wales, Cardiff

Key words: Subclavian

artery

obstruction, angioplasty

A series of 12 consecutive cases of symptomatic subclavian artery stenosis or occlusion treated by percutaneous transluminal angioplasty are described. In seven cases stenoses were successfully dilated, and in four out of five cases occlusions were recanalised using standard angioplasty technique. Complications were trivial and did not prolong hospital stay, all patients being discharged within 48 h of the procedure. Percutaneous transluminal angioplasty of the subclavian artery is a safe, effective procedure and recommended as the treatment of first choice in symptomatic subclavian stenosis or occlusion.

Dotter and Judkins first described percutaneous dilatation of femoral artery stenoses, using coaxial catheters of increasing size, in 1964 (1). The procedure was named 'percutaneous transluminal angioplasty (PTA)'. Despite their encouraging results, PTA met with scepticism in the USA and much of its further development took place in Europe where by 1974 Gruntzig and his colleagues had developed a flexible balloon catheter which replaced the bouginage of the Dotter technique with the localised circumferential force of an expanding balloon (2). PTA was no longer confined to arteries near to and in line with the introduction site, and it found application throughout the body. The first report of subclavian artery angioplasty appeared in 1980 (3). Surgical reconstruction has been the traditional method of treating subclavian obstruction, but a number of studies have now shown subclavian artery PTA to be safe and effective (4-8). We present seven cases of subclavian stenosis and five cases of subclavian occlusion Present appointment: Consultant Radiologist, Hull Royal Infirmary, Kingston upon Hull. Correspondence to: Dr M S Ruttley, Department of Radiology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW *

illustrate the indications for angioplasty, technique, results and complications. to

Patients and methods Over a period of 6 years, nine females and three males, aged between 35 and 71 years, underwent subclavian angioplasty by, or under the supervision of, one radiologist. All had arm claudication or acute digital ischaemia and/or neurological symptoms and arteriographically proven subclavian artery stenosis of at least 50% diameter or an occlusion with an identifiable origin, stump and patent distal vessel. In each case the need for intervention (angioplasty or surgery) was decided by the referring clinician, angioplasty agreed at clinicoradiological conference and, with the patient's informed consent, scheduled as an inpatient procedure. Aspirin (300 mg daily) was started at least 24 h beforehand, oral diazepam (10 mg) was given as premedication and all procedures were carried out under local anaesthesia. Selective subclavian artery catheterisation was performed under fluoroscopic control with an angiographic catheter (100 cm 5G Mani or 7G Head Hunter-William Cook Europe Ltd) introduced percutaneously through the femoral artery at the groin. Confirmation of the previous angiography was followed by injection of 5000 units of heparin. A 145 cm long x 0.096 cm diameter Teflon® coated guidewire was then advanced through the catheter and, where possible, across the stenosis or occlusion. If the lesion could not be crossed antegradely, a retrograde attempt from a percutaneous axillary artery catheterisation or a brachial artery cut-down was made. Successful passage was judged by free movement of the wire in the distal artery and confirmed by catheter advancement, then wire removal

Percutaneous transluminal angioplasty of the subclavian artery and contrast medium injection. In some cases catheter tip pressure monitoring through a fluid-filled manometer line linked to a pressure transducer and recorder was also available. Once across the lesion, the angiographic catheter was exchanged over a 260 cm x 0.096 cm wire for an 8G angioplasty catheter (Medi-tech Inc) with a balloon diameter of either 6 or 8 mm (distended) depending on the angiographic size of the subclavian artery. The balloon segment of the catheter, indicated by metallic markers, was placed across the lesion and the 0.096 cm wire then replaced with a non-occluding 0.0635 cm wire. This allowed contrast medium injection and catheter tip manometry when available, catheter position being guaranteed by the guidewire. The balloon was then distended with dilute contrast medium injected through a pressure gauge at the catheter hub; the fluoroscopically visible waist imposed on the distending balloon by the lesion was abolished in all successful cases by 1-3 distensions of up to 6 atm pressure. The balloon was then collapsed by negative syringe pressure and withdrawn across the lesion (leaving the wire in place for further passage if necessary) and the angioplasty site checked by angiography and/or pressure measurement. Success was arbitrarily judged as a residual diameter stenosis of less than 25% and/or a residual pressure gradient of less than 10 mmHg across the lesion, unaltered by a further balloon distension. The procedure was terminated by catheter and wire removal and pressure haemostasis at the percutaneous puncture site. Arterial repair was performed in the one case with brachial cut-down. All patients were discharged between 24 and 48 h later and continued on aspirin 300 mg daily. Outpatient clinic follow-up has varied between 1 month for the most recent case and 6 years for the earliest; clinical assessment of the radial pulses and differential arm cuff blood pressures were obtained at each visit.

Results Table I gives details of patients' age, sex, risk factors, angiographic findings, results and complications of angioplasty and clinical summaries before and after the procedures. Eight patients had successful angioplasty from percutaneous femoral catheterisation; this route failed in Cases 3, 4, 7 and 10 due to tortuosity of the aorta, but success was achieved from the percutaneous axillary route in three of these (Fig. 1) and from a brachial artery cut-down in Case 7. Angioplasty failed in Case 2 where an occlusion extended from 0.5 cm above the left subclavian origin to a point immediately proximal to the vertebral artery. The lesion was crossed with a wire but this persistently entered the vertebral artery beyond and the procedure was abandoned to avoid vertebral damage. A subsequent axilloaxillary graft was successful initially but occluded at 3 years with return of symptoms. In Case 1, a previous axilloaxillary graft for right subclavian artery occlusion thrombosed before the onset of left digital ischaemia and subsequent left subclavian angioplasty. The left radial pulse was consequently stronger

47

than the right after angioplasty. Thus, 11 patients had successful subclavian angioplasty with abolition of systolic pressure difference between their arms (except for a 10 mmHg residuum in patient 7) and return of the radial pulse. Nine patients have remained asymptomatic for periods varying from 1 month to 6 years. In Case 7 symptoms of left arm claudication returned at 7 months when a repeat arteriogram demonstrated patency at the angioplasty site but new distal stenoses. In Case 6, the patient was asymptomatic at 1 year but at 5 years she had mild claudication, and though her radial pulses were equal, Doppler signals were damped on the left, suggesting collateral circulation. The only recorded complications were a groin haematoma (Case 5) and an axillary haematoma (Case 4). The latter patient also suffered a vasovagal episode during the procedure, treated by parenteral atropine. The haematomas did not require intervention or prolong hospital stay.

Discussion All the patients in this series had one or more risk factors for atherosclerosis and, except for Case 5 with Raynaud's phenomenon, no symptoms, signs or simple laboratory markers (abnormal ESR or plasma proteins) of other cardiovascular disease. Echocardiography was negative in patients who presented with digital ischaemia. Atherosclerosis was therefore the assumed cause for the arterial lesions, but pathological proof was not available or sought. The majority of the patients presented with simple arm claudication indicating inadequate perfusion pressure beyond a subclavian obstruction. In five cases of proximal subclavian obstruction there were symptoms consistent with vertebrobasilar insufficiency secondary to reversed vertebral arterial flow sustaining arm perfusion at the expense of the cerebral circulation. This vertebral arterial flow reversal (the subclavian steal syndrome) was shown angiographically in all five before angioplasty and was correct d by the successful procedure. In the six cases of subclavian artery stenosis or occlusion with acute digital ischaemia, arterial emboli were assumed to have arisen from the proximal lesion in the absence of any other cause, though one patient had Raynaud's phenomenon. It is tempting to attribute the absence of further embolic episodes after angioplasty to the smoothing of the treated segment in the healing phase which is well recognised angiographically (9). Similar improvement has been recorded after femoropopliteal angioplasty in the blue toe syndrome (10); however, the majority of these patients and all of ours were started on aspirin at the time of the mechanical intervention and no valid conclusion can be reached from these few cases. Traditionally, symptomatic subclavian artery obstruction has been treated by endarterectomy or bypass surgery. The reported mortality for the transthoracic approach is between 0 and 18%, with a morbidity rate of 23% (11,12). Thrombosis at the endarterectomy site, chylothorax, pneumothorax, pleural effusion, lymphatic

48

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A A Nicholson et al.

Figure 1. (a) Preangioplasty. Anteroposterior (AP) projection. Arch aortogram. Stenosis in the first part of the left subclavian artery (arrowed). (b) Postangioplasty. (AP) projection. Stenosis dilated successfully from the transaxillary route. Note the metal marker on the angioplasty balloon.

fistulas, phrenic nerve palsy, and Homer's syndrome are the most serious complications. Extrathoracic subclavian to common carotid anastomosis is safer, with no reported mortality and low morbidity. Axilloaxillary bypass graft is also safe and technically simpler (11), but reported complications include haemorrhage, laryngeal injury, lymphatic fistulas, ptosis (following division of sympathetic fibres passing over the vertebral artery), infection and complications of general anaesthesia. Surgery is still the preferred treatment in some centres but this and other reported series (4-8) suggest that angioplasty is at least as effective with a lower complication rate and a much shorter hospital stay. It may be that reluctance to perform angioplasty is based on limited knowledge of the procedure or fear of vertebral artery origin damage and embolisation to either the vertebral or digital arteries. Vertebral artery damage is rare even when the angioplasty balloon is dilated across the origin of that vessel (13). Clinically significant distal embolisation is rare after any angioplasty (14) and Doppler sonography has demonstrated that return of vertebral flow from retrograde to antegrade does not occur immediately after PTA for subclavian steal but over the following 20 seconds to several minutes (15), thus protecting the vertebral artery from PTA-induced embolism. The risk of new neurological or ischaemic sequelae following subclavian PTA is therefore very small.

We include five cases of subclavian artery occlusion (Fig. 2), four of which underwent successful angioplasty. Two of these patients were asymptomatic at follow-up and one had only mild arm claudication. Subclavian artery occlusion is therefore not a contraindication to angioplasty. In most series like ours, left subclavian artery angioplasty predominates over right, perhaps because right subclavian artery occlusion is less common and perhaps also because of some reservation over angioplasty at a site near the right common carotid origin. Our series includes a right subclavian artery stenosis successfully dilated without complication (Fig. 3). PTA has a high success rate as this series shows, and failure does not preclude subsequent surgery. The results presented here are similar to series of angioplasty in comparable sized arteries elsewhere in the body (16) and to other series of subclavian artery angioplasty (4-8). There have been no significant complications in this and other series, though one case of brachial artery occlusion has been reported (7). Though the axillary route is a more direct approach to the subclavian artery, there is an increased risk of complications such as brachial plexus compression, and the transfemoral route is preferred. We believe that percutaneous transluminal angioplasty of proximal or distal subclavian artery stenosis or occlusion is a safe, effective procedure and is the treatment of

Percutaneous transluminal angioplasty of the subclavian artery

51

Figure 2. (a) Preangioplasty. AP projection. Arch aortogram. Left subclavian artery occlusion just beyond origin with an identifiable stump (arrowed). (b) Postangioplasty arch aortogram. Successful dilatation.

Figure 3. (a) Preangioplasty. Right anterior oblique (RAO) projection. Selective right brachiocephalic artery injection. Stenosis at the origin of the right subclavian artery. (b) Postangioplasty. (RAO) projection. Successful dilatation from the transfemoral route.

52

A A Nicholson et al.

choice for subclavian steal, arm claudication or digital ischaemia caused by such lesions. We would like to thank the physicians and surgeons of Wales for referring these patients, in particular Messrs G E Heard, W T Davies, I E S Lane and also Dr Mohammed Al Fagih for case number 8. We would also like to thank Mrs C J Gardiner for preparing the manuscript.

References I Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction. Description of a new technique and a preliminary report of its application. Circulation 1964;30:

654-70. 2 Gruntzig A, Hopff H. Perkutane Rekanalisation chronischer arterieller Verschlusse mit einem neuen Dilatationskatheter. Modifikation der Dotter-Technik. Dtsch Med Wochenschr 1974;99:2502-5. 3 Bachman DM, Kim RM. Transluminal dilatation for subclavian steal syndrome. AJR 1980;135:995-6. 4 Galichia JP, Bajaj AK. Subclavian artery stenosis treated by transluminal angioplasty. Six cases. Cardiovasc Intervent Radiol 1983;6:78-81. S Gordon RL, Haskell L. Transluminal dilatation of the subclavian artery. Cardiovasc Intervent Radiol 1985;8: 1419. 6 Motarjeme A, Keifer JW. Percutaneous transluminal angioplasty for treatment of subclavian steal. Radiology

7 Erbstein RA, Wholey MH, Smoot S. Subclavian artery steal syndrome. Treatment by percutaneous transluminal angioplasty. AJR 1988;151:291-4. 8 Cook AM, Dyet JF. Six cases of subclavian stenosis treated by percutaneous angioplasty. Clin Radiol 1989;40:352-4. 9 Castaneda-Zuniga WR, Formanek A, Tadavarthy M. The mechanism of balloon angioplasty. Radiology 1980;135: 565-71. 10 Brewer ML, Kinnison ML, Perler BA, White RI. Blue toe syndrome: treatment with anticoagulants and delayed percutaneous transluminal angioplasty. Radiology 1988;166: 31-6. 11 Beebe HG, Stark R, Johnson ML. Choices of operation for subclavian-vertebral arterial disease. Am J Surg 1980; 139:616-23. 12 Thompson BW, Read RC, Campbell GS. Operative corrections of proximal blocks of the subclavian or innominate arteries. J Cardiovasc Surg 1980;21:125-30. 13 Vitek JJ. Subclavian artery angioplasty and the origin of the vertebral artery. Radiology 1989;170:407-9. 14 Block PC, Elmer D. Release of atherosclerotic debris after transluminal angioplasty. Circulation 1982;65:950-2. 15 Ringelstein EB, Zeumer H. Delayed reversal of vertebral artery flow following P.T.A. for subclavian steal syndrome. Neuroradiology 1984;26:189-98. 16 Van Andel GJ, Van Erp FM. Percutaneous transluminal dilatation of the iliac artery: long term results. Radiology 1985;156:321-3. Received 28 June 1990

1985;155:611-13.

Assessor's comment This group are to be congratulated that in none of the cases of digital ischaemia or subclavian steal syndrome was there clinical evidence of further embolic event in the immediate postangioplasty period. This would suggest that the procedure is relatively free of risk. Also, four out of five cases of subclavian occlusion were successfully recanalised without mishap. The authors make a good case for the use of this simpler and effective treatment for symptomatic subclavian artery stenosis or occlusion over

the more invasive surgical procedures. This trend is already in evidence in the more common symptomatic and occlusive lesions in the lower limb ischaemia, and points the way to future developments in the field. M ADISESHIAH

FRCS

Consultant Vascular Surgeon University College Hospital London