1. SCAI Fall Fellows Course 2012 Subclavian/Innominate Case Presentation Daniel J. McCormick DO, FACC, FSCAI Director, Cardiovascular Interventional Therapy Pennsylvania Hospital University of Pennsylvania Helath System

2. DISCLOSURES  Educational Grants: Cordis, Boston Scientific, Abbott Vascular, St. Jude,  Research Grants: Cordis, Boston Scientific, Gore, St. Jude, Abbott Vascular

3. CASE  57 yo man, suffered syncopal episode while removing packages from his car  PMH: DM, Htn, Dyslipidemia,  SH: former heavy tobacco usage, works as janitor  ROS: +R. arm fatigue with activity, occasional transient episodes of dizziness; Negative history of arrhythymia

4. CASE Continued  PE: L arm with 40 mm Hg greater than right arm  Cardiac exam unremarkable  Vascular: Diminished R. carotid pulse c/w left  Referred for Vascular Duplex Study

5. C Carotid Duplex

6.  Mild plaque in the R. CCA/ICA with diminished flow  R. ECA with reversal of flow  R. Vertebral/Subclavian with retrograde flow  L. ICA with mild stenosis  L. vertebral artery with antegrade flow  Summary: Features consistent with subclavian steal

7. MRI Angiography of Neck  Patent but diffusely smaller R. CCA  Moderate stenosis of R. innominate artery suspected  Normal caliber and flow in L. CC/IC arteries  Normal flow in L. vertebral and reversal of flow in R. vertebral artery

8. Arch Angiogram – 95% Innominate Stenosis

9. Ostial Innominate Angiogram

10. Left Common Carotid Angio

11. Left Vertebral Angiogram

12. Diagnostic Angiography  Type I Aortic Arch  Innominate artery with 90% lesion at ostium  R. vertebral artery not visualized on innominate angiography  Mild disease of L. carotid system  L->R crossover on intracerebral angiography  Collateralization of R. hemisphere from L. external carotid  L. vertebral angiography fills R. vertebral via patent Circle of Willis

13. Innominate Angio w 9fr JR4 Guide

14. Double.014 Guidewires- Nav6 EPD advanced to LICA

15. NAV6 EPD Deployment RICA

16. 6 x 20 Viatrac Balloon over 2 0.14 Guidewires

17. Post – PTA Result

18. 10 x 29 Omnilink Stent

19. Stent Deployment

20. Post-Stent w EPD in RICA

21. Final Angiogram Right Innominate Ostial Stent

22. Endovascular Intervention  Pre-close with 9 F sheath  9 F JR4 guide  Nav6 0.14 EPR wire in R. ICA, Spartacore 0.14 in R. axillary  NAV6 filter in R.ICA  6 x 20 mm Viatrac balloon angioplasty  10 x 29 Omnilink BES deployed over 2 wires  Subsequent visualization of R. vertebral artery  Successful Innominate Stenting with EPD and 2-wire technique

23. Post-Procedure  Patient doing well over 3 months out from stenting  No further syncope, arm claudication  Upper extremity blood pressures essentially equal  Carotid duplex U/S: –Antegrade R. vertebral flow

24. Clinical Manifestations  Arm claudication, hand or finger pain  Paresthesias, Raynaud’s phenomenon  Ischemic Neurologic Syndromes  Vertebral-subclavian steal –vertigo, syncope, ataxia, diplopia, motor deficits  Coronary-subclavian steal –angina, infarction

25. Diagnosis  Diagnosis of the lesion –Clinically: Blood pressure difference >20 mmHg ( Segmental blood pressures) –Duplex scan –M.R.I. OR M.R.A. –CTA Scan –ARTERIOGRAPHY REMAINS THE GOLD STANDARD

26. Surgery vs. Endovascular Approach Carotid-subclavian bypass Stent 100% left subclavian 70% stenosis 35mm Grad

27. Endovascular Therapy Approach  Femoral approach: –Larger catheters or sheaths could be used –Easy for stenotic lesions –Difficult for occlusions and ostial lesions  Brachial approach: –Difficult upstream visualization –Best for occlusions –Useful after failure of femoral approach  Combined Femoral/Brachial approach for occlusions with pull through wire snare technique ( “ Body Floss ” )

28. Endovascular Therapy Basic Equipment  Selection of equipment depends on lesion anatomy and approach  Guiding catheters 8F –Multipurpose –Judkins right OR …  Introducer sheaths 6 -7F / 60- 90cm - PREFERRED  Guide wires: –0.035 Hydrophilic –0.035 Super stiff amplatz/ Magic Torque –0.014 Coronary wires, only when using EPD

29. Innominate Subclavian PTA / Stenting  Pre-vertebral Location/ostial lesion: –Balloon expandable stents Greater radial force More accurate placement –Avoid covering vertebral artery and IMA –Stent should protrude into aorta by 1-2 mm –Select at least >= 20 mm long stents –Deflate balloon/stents balloon slowly –Avoid matching stent size to the post-stenotic dilatation –Mild residual stenosis is acceptable

30. AVOID EXCESSIVE CATHETER MANIPULATION

31. MRI Brain w/o contrast

32. Complications –Distal embolic events –Brachial artery thrombosis –Reperfusion arm edema + compartment syndrome –Stroke (infarct or hemorrhage) –Restenosis and stent fracture –Access complications (pseudoaneurysm, hematoma)

33. Technical Considerations: Lesions to Avoid  Extreme tortuosity  Lesion adjacent to an aneurysm  Presence of fresh thrombus  Long total occlusion with extensive calcification

34. Take Home Points  Indications for RX: –VBI, Carotid steal syndrome, UE ischemia, Digital emboli  Need for EPD remains undetermined, rarely reported in the literature  2 wire technique can be useful in subclavian/innominate intervention and allows Internal Carotid EPD

35. Learning Curve

36. Anatomy

37. Take Home Points  Atherosclerotic occlusive disease involving aortic arch branches common in patients older than 65  Innominate artery stenosis (IAS) is uncommon –However, assoicated with significant morbidity –Important cause of symptomatic extracranial cerebrovascular disease  IAS natural history not well known

38. Take Home Points  Most common etiologies in US: atherosclerosis and Takayasu’s arteritis  Symptoms: –Arm claudication, paresthesias, weakness –Vertigo, syncope, transient quadriparesis  Surgical revascularization was the historical standard but it requires median sternotomy and is associated with significant morbidity and mortality (10%) 1  Endovascular intervention has become considered optimal first-line therapy 1 Ryer et al. J Endovasc Ther 2010