Complex Ostial Disease of the Aortic Arch Vessels CRT 2016 Thoracic February 23, 2016

Christian Shults, MD   I have no relevant financial relationships

Incidence and background Thought to be an extension of aortic disease Correlation with CAD (4-7%), (66% have CAD) Correlation with PAD (11.5%) High correlation with smoking (78-100%), HTN, HLD, PAD Younger than typical PAD patients

4748 patients with symptomatic cerebrovascular disease

Subclavian/Innominate Stenosis Subclavian most affected brachiocephalic vessel by atherosclerosis L>R Hypoperfusion vs. emboli Differential BP >20mmHg ~20% symptomatic Left then right carotid Innominate lesions uncommon Usually proximal extension of Left subclavian disease or aortic arch

Symptomatic Presentation Vertebrobasilar ischemia “subclavian steal” Fisher et al N Engl J Med 1961 Dizziness, vertigo, unsteadiness/imbalance, syncope… Upper extremity claudication Fatigue, pain with exercise, “heaviness” Upper extremity ischemia Rest pain, tissue loss, ulceration Coronary steal CABG and LIMA-LAD bypass Neurologic dysfunction(ant/post circulation); UE symptoms Innominate lesions Ulcerated plaques in Innominate or CCA: TIA, neurologic dysfunction

Repair Symptomatic lesions Asymptomatic occlusion or stenosis does not typically warrant repair due to collateral network Reversal of vertebral not indication unless symptomatic Symptomatic coronary steal or in preparation for CABG.

Treatment Transthoracic approach Extrathoracic approach Endarterectomy Bypass Innominate stenosis More than one large vessel Extrathoracic approach Single vessel Endovascular approach First line

Trans-thoracic approach 10 year patency rates 88-94% in the largest series Operative mortality rates 3-6% Operative stroke rates 3-10%

Surgical Revascularization Innominate artery bypass/endarterectomy More Invasive Excellent patency Ernst&Stanley Current Therapy in Vascular Surgery

Innominate Endarterectomy Disease limited to the distal 2/3rd More extensive or involving the ostium, bypass should be performed. Plaque extends beyond the origin of subclavian or carotid..bypass. Bovine Arch, contraindicated

Set up Arterial lines EEG Cerebral oximetry Test Clamp Leave innominate vein Place grafts over the innominate vein

Extrathoracic approach Not endovascular candidate, single vessel disease, too much co-morbidity for transthoracic 10 year patency rates: 82-88% Operative mortality: 0.3 – 0.5% Operative stroke rates: 1-4%

Extra-thoracic Approach Subclavian transposition Minimal morbidity Excellent long-term patency Carotid subclavian bypass Minimal morbidity Excellent long-term patency

Endovascular Management Feasibility Access Cross lesions Respond to treatment Morbidity Dissection (subclavian) Neurologic events Insertion site thrombosis/hematoma Patency Technical Clinical

Technique Method of approach Prepared for both Antegrade Retrograde Percutaneous Patient comfort Operator friendly Retrograde More support for manipulations Avoidance of arch work Preferable ostial and occlusive lesions Prepared for both

Endovascular Approach No perioperative deaths or strokes 3 year patency 88% 3 year re-intervention rate 7%

Stenting Stenting preferred over PTA alone? any residual narrowing or gradient dissection Type of stent dictated by circumstance Balloon-mounted Self-expandable

Protective Measures Protective wire vertebral/subclavian DEP-distal embolic protection device Subclavian:? Innominate:?

Summary Transthoracic: Extrathoracic: Endovascular: 10 year patency rates 88-94% in the largest series Operative mortality rates 3-6% Operative stroke rates 3-10% Extrathoracic: 10 year patency rates: 82-88% Operative mortality: 0.3 – 0.5% Operative stroke rates: 1-4% Endovascular: 3 year patency rates: 88% No perioperative deaths or strokes 3 year re-intervention rate 7%

Conclusion Treatment of ostial subclavian/carotid/innominate lesions limited to symptomatic patients Patient tailored approach Endovascular first, depending upon anatomy (innominate bifurcation lesion) Role of distal protection Younger healthy patients with complex lesions Better long term patency with open