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

2. Christian Shults, MD
I have no relevant financial relationships

4. 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

5. 4748 patients with symptomatic cerebrovascular disease

6. 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

7. 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

8. 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.

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

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

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

16. 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

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

18. 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%

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

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

23. 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

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

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

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

27. 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%

28. 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