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Percutaneous Transluminal Angioplasty of the Brachiocephalic Arteries

Amir Motarjeme 1 Percutaneous transluminal angioplasty was used to treat atherosclerotic lesions in John W. Keifer 22 brachiocephalic arteries in 20 patients during a 2'/2 year period. Seven subclavian, Albert J. Zuska 13 vertebral, one external carotid, and one common carotid arteries were involved. Nineteen arteries were successfully dilated, but dilatation of two vertebral arteries and attempted recanalization of one subclavian artery failed. The first patient treated was still asymptomatic at 30 months and no symptoms recurred in any of the successfully treated patients. No complications were encountered during these procedures

Since the introduction of the balloon dilatation catheter by Gruntzig and Hopff [1] in 1974, transluminal angioplasty, originally described by Dotter and Judkins [2], has been widely used to treat atherosclerotic occlusive disease of the coronary, renal , iliac, and femoral arteries [3-9]. However, transluminal angio­ plasty of brachiocephalic arteries has been only rarely performed due to fear of cerebral emboli. We have reported successful dilatation of the vertebral arteries [10], and, in this paper, we describe our experience in dilatation of th e brachi­ ocephalic arteries during a 2 '/2 year period.

Subjects and Methods

Transluminal angioplasty of seven subclavian, 13 ve rtebral, one external carotid , and one common carotid arteri es was attempted in 13 men and seven women 57 - 84 years old.

Subclavian Artery

Seven patients, two women and five men, were treated for subclavian stenosis, all on the left side. Two patients had claudicati on and numbness of th e arm due to severe subclavian stenosis distal to th e vertebral artery. Five patients had occlu sive disease proxim al to th e ve rtebral artery, three with symptoms of subclavian steal, all complaining of severe dizziness. Interarterial pressures were measured in all patients, both in pre- and poststenoti c areas. The gradients were greater th an 70 mm Hg in all patients and as hi gh as 100 mm Hg This article appears in the March 1982 issue in one with subclavian steal. of AJR and the March/ April 1982 issue of AJNR. After se lecti ve cath eterizati on of th e subclavian artery, th e stenosis and th e ori gin of the vertebral artery were marked on the skin with a lead marker to point out th e site of dil atati on Received April 28, 1981; accepted after revi­ and to prevent accidental dilatation at th e origin of the ve rtebral artery. Stenoses in sion November 2, 1981. symptomati c subc lavian arteri es are usuall y ti ght and do not accommodate a J guide wire, Presented at the annual meeting of the Ameri­ thus a selecti ve catheter is placed just proxim al to th e stenosis and a soft, straight guide can Roentgen Ray Society, San Francisco, March 1980. wire is carefully advanced past th e stenosis, th en foll owed by the angiog raphi c catheter. The straight guide wire is th en exchanged for a long exchange J guide wire, which is ' All authors: Departm ent of Radiology, St. Anne 's Hospital, 4950 W. Thomas St., Chicago, inserted well beyond the stenosis into th e ax illary art ery. Th e angiog raphic catheter is then IL 60651 . Address reprint requests to A. Motar­ exchang ed for a proper sized balloon cath eter (a balloon 1 cm longer th an th e length of th e jeme. stenosis with a diameter 1 mm small er th an th e norm al artery di stal to th e stenosis) . A AJNR 3:169-174, March/ April 1982 balloon diameter of 8 - 9 mm is usuall y required for dil atation of proximal lesions. It is 0195-6108/ 82/ 0033-0169 $00.00 advisable to keep the guide wire in place durin g dil atati on of proximal lesions to prevent © American Roentgen Ray Society the balloon cath eter from sliding back into th e aorta. The ball oon is inflated by hand usin g 170 MOTARJEME ET AL. AJNR:3, Marchi April 1982

dilute contrast medium. A postangioplasty arch aortogram is ob­ Results tained in all pati ents with proximal lesions, and subclav ian arterio­ grams are obtained in pati ents with lesions di stal to th e vertebral Subclavian Artery artery. Of seven patients with occlusive lesions of the subclavian artery, five were successfully treated with percutaneous Vertebral Artery transluminal angioplasty. Two had stenoses distal and three proximal to the vertebral artery. One of the proximal lesions Dilatati on of 13 vertebral arteri es was attempted in 11 patients was associated with subclavian steal, which was corrected (both ve rtebral arteri es in two pati ents) complaining of th e typical immediately by dilatation. Postangioplasty arteriograms re­ symptoms of ve rtebral basil ar in suffic iency: dizziness, blurred vi­ vealed normal-appearing arteries, and pressure gradients sion, ataxia, and drop-attack. A complete angiographi c assessment of th e cerebral circulation, including both carotid arteri es and were abolished. All five patients became symptom-free. ve rtebral basil ar system, was made in all pati ents. Five patients had Partial dilatation was achieved in proximal subclavian isolated ve rtebral artery disease, while the oth ers had had carotid artery stenosis in a 58-year-old man with subclavian steal , artery stenosis treated by arterectomy without relief of symptoms. complaining of severe dizziness. Arterial pressure gradient Both vertebral arteri es were successfully dilated in one pati ent. was diminished from 100 mm Hg to 40 mm Hg, but no Transluminal angioplasty was perform ed only when stenoses were immediate reversal of the vertebral artery flow was seen. at th e origin of th e vertebral artery and only when th ere was no Postangioplasty arteriogram showed increased lumen of the additional occlu sion of th e vertebral basilar system. Pati ents with disease subclavian artery. The patient's dizziness improved, both vertebral and carotid artery stenosis were first treated with but was not totally alleviated. carotid endarterectomy and vertebral artery dilatation was only Attempted recanalization of a totally occluded subclavian considered if th e symptoms were not relieved . Furthermore, trans­ luminal dilatation was performed when reconstructive vascular sur­ artery in a patient with subclavian steal failed. This patient gery was warranted and , in som e, already pl ann ed . was subsequently treated with carotid subclavian bypass. After selective catheterization of th e vertebral artery, vi a femoral artery, an exchange guide wire, usually straight, was advanced well beyond th e point of stenosis. With th e guide wire in place, th e Vertebral Artery angiog raphic cath eter was exchanged for a 7 French Gruntzig balloon cath eter, having a balloon 1 cm long and 4 mm in diameter. Eleven vertebral arteries, eight on the left and three on Th e ball oon was inflated by hand using dilute contrast medium for the right, were successfully dilated in 13 attempts. The about 5 sec and repeated two or three tim es. Th e ball oon cath eter procedure failed in two arteries due to tortuosity of the was th en withdrawn back to th e subclavi an artery and a postangio­ vertebral artery in one and the right subclavian artery in plasty subclavian arteri ogram was routinely obtain ed. No intraarter­ one. Both vertebral arteries were successfully dilated in one ial pressures were measured since th e cath eter occludes th e lumen patient. Carotid endarterectomy was ineffective in relieving of th e vertebral artery. Dilatation was considered successful wh en th e postangioplasty arteriogram showed a normal-appearing artery symptoms in four patients having both vertebral and carotid or considerably increased lumen of the artery (at least 50%) and if stenoses, but the symptoms were relieved with dilatation of th e vertebral basilar in sufficiency symptoms were reli eved. the vertebral artery. Arteriotomy and venous patch of the left vertebral artery in a patient with bilateral vertebral artery stenosis diminished his dizziness, but it was only entirely Carotid Artery relieved after successful dilatation of the right vertebral An gioplasty of one extern al and one common caroti d artery was artery. attempted in two patients. Both procedures were perform ed intra­ operati ve ly during carotid bifurcation endarterectomy. The extern al carotid artery was dil ated in a pati ent who underwent end­ Carotid Artery arterectomy for treatm ent of an ulcerated plaque at caroti d bifur­ cation. Th e common carotid artery was dilated in a man who had An external and a common carotid artery were success­ stenosis of both th e proximal common carotid and th e intern al fully dilated intraoperatively in two patients. The external carotid arteri es. Th e stenoses were approached through th e end­ carotid artery was seen to be completely dilated on a 6 art erectomy incision usin g a J guide wire to lead th e angioplasty month postangioplasty arteriogram (fig. 1). A 50% stenosis cath eter through th e stenosis. Th e intern al carotid artery was oc­ of a common carotid artery was improved to a 20% stenosis. cluded by a Javid shunt during dilatati on of the common carotid artery. A 9 French cath eter, having a balloon 3 cm long and 9 mm in diameter, was required for dilatati on of th e common carotid artery. Representative Case Reports No anticoagul ati on treatment was used during or after angio­ Case 1 plasty procedures in the first 15 cases, but th e rest of th e patients were treated with 8, 000 U of heparin intraarteri all y immediately An 84-year-old woman had numbness and c laudication of her left after initial cath eteri zati on. The heparin anticoagul ati on was always arm for 6 months. Brachial systolic blood pressure was 190 mm Hg reversed with protamine before removal of th e cath eter. No anti­ on th e right but only 104 mm Hg on th e left. A selecti ve left coagulati on treatment was given after th e dilatation procedure but subclavian art eri ogram showed severe stenosis distal to th e ve rte­ pati ents were treated with Persantine 75 mg three tim es a day bral artery (fig. 2A) . An 80 mm Hg gradi ent was measured across before and after transluminal angiopl asty. th e stenosis. The stenosis was dilated using a 7 French Gruntzig AJNR:3, Marchi April 1982 PTA OF BRACHIOCEPHALIC ARTERIES 171

Fig. 1.-61 -year-old man with weakness of right arm. Carotid arteriogram showed ulcerated plaque of common and internal carotid arteries in addition to severe stenosis of extern al carotid artery. Extern al carotid artery was dilated in tra­ operati vely. A, Ulcerated plaque of posterior as­ pect of internal carotid artery. Severe stenosis of external carotid artery (arrow). B, Postangioplasty arteriog ram 6 months later. Complete dilatation of external carotid artery (arrow). Small linear de­ fects are surgical clips used during carotid end­ arterectomy.

A B

Fig. 2. -Case 1, 84-, " dr-old woman with clau­ dication and numbness of left arm . A, Selective subclavian arteri ogram. Severe stenosis distal to vertebral artery (arrow). B, Postangioplasty arte­ riog ram. Complete dilatation and normal-appear­ ing arterial lumen (arrow).

A B

balloon catheter 1 cm long and 6 mm in diameter. Postangioplasty Case 3 intraarterial pressure measurements showed no gradient, and a A 72-year-old man had dizziness. A four-vessel cerebral arteri o­ postangioplasty arteriogram showed a normal-appearing artery (fig. gram revealed no carotid artery disease, but there was severe 28). Claudication and numbness disappeared and the patient was stenosis of th e origin of both vertebral arteries (fig . 4A). Percuta­ still asymptomatic after 2'12 years. neous transluminal angioplasty of both ve rtebral arteri es was at­ tempted, but onl y the left one was su ccessfully dilated (fig. 48). Dilatation of th e right vertebral artery was tec hnicall y unsuccessful Case 2 due to tortuosity of the right subclavian artery. The dizziness was all eviated and the patient was still asymptomati c 6 months aft er th e A 54-year-old man had dizziness for 1 year. A four-vessel cere­ procedure. bral arteriogram showed no carotid artery disease, but th ere was severe stenosis of th e proximal left subclavian and the origin of th e right vertebral arteri es (figs. 3A and 38). Th ere was 70 mm Hg Case 4 gradient across th e stenosis of th e subclavian artery. Percutaneous transluminal angioplasty of the left subclavian artery relieved the A 62-year-old man had severe dizziness and occasional numb­ stenosis and th e arterial gradient (fig. 3C). The patient had no ness of the left arm . A four-vessel cerebral arteriogram revealed no further dizziness and was still asymptomatic after 2 years. carotid artery or intracranial occlu sive disease, but th ere was severe 172 MOTARJEME ET AL. AJNR:3, Marchi April 1982

A B c Fig, 3.-Case 2, 54-year-old man wi th dizziness. A, Stenosis of proximal of right vertebral artery (arrow ) also. C, Postangioplasty arteriogram. Dilata­ lell subclavian arlery (arrow ). B, Arch aortogram in oblique posilion. Stenosis tion of left subclavian artery (arrow).

Fig . 4.- Case 3, 72-year-..J ld man with severe dizziness that prevented walking. Carolid arteri o­ gram (not shown) showed no occlusive disease. A, Left subclavian arteri ogram. Severe stenosis of ori gin of lell ve rtebral artery (arrow). B, Postangio­ plasty subclavian arte riogram. Di latation of verte­ bral artery stenosis (arrow).

B

stenosis of the left subclavian artery with a subclavian steal (figs. Discussion 5A and 5 8). There was 100 mm Hg pressure gradient across the stenosis. The subclavian artery was dilated, but the subclavian steal Endarterectomy of the carotid artery bifurcation is a rather \ as not immediately corrected (fig. 5C). Postangioplasty arterial simple and generally effective procedure, but surgical treat­ pressure measurements indicated a 40 mm Hg residual pressure ment of subclavian vertebral artery disease is more complex. gradient. The patient continued to have occasional mild diz.ziness, Many patients with subclavian artery disease undergo an but refused the option of reconstructive vascular surgery. intrathoracic operation for endarterectomy or bypass sur- AJNR:3, MarchI April 1982 PTA OF BRACHIOCEPHALIC ARTERIES 173

A B C

Fig . 5.-Case 4, 62-year-old man with severe dizziness. occasional numb­ Retrograde flow of vertebral artery in subclavian steal. C, Postangioplasty ness of left arm , and one episode of drop attack. A, Arch aortogram. Almost arch aortogram. Improved stenosis of subclavian artery (arrow), however. total occlusion of proximal subclavian artery in subclavian steal (arrow). B, subclavian steal is not corrected.

gery. More recently extrathoracic approaches, such as ca­ at the origin of the artery and in the absence of additional rotid subclavian, axi lloaxillary, and femoroaxillary bypass atherosclerotic disease in the vertebral basilar system or graft, have been used [11]. Complication rates ot' both the carotid arteries. Vertebral artery dilatation should only be intrathoracic and extrathoracic operations are similar and attempted if surgery is warranted and can be scheduled as reported to be as high as 23% [11]. Chylothorax, end­ a back-up measure. arterectomy thrombosis, pneumothorax, pleural effusion, The importance of the external carotid artery as a source neck lymph fistula, phrenic nerve palsy, and Horner syn­ of collateral blood supply in carotid artery occlusion is well drome are among the most serious and worthy of mention. established [12]. There are several reports of total recovery We believe transluminal angioplasty, on the other hand, from recurrent transient cerebral ischemia after end­ is an effective nonsurgical treatment with fewer complica­ arterectomy of the external carotid artery in patip-nts with an tions when it is applied in selected cases. Our series, occluded carotid artery [13-1 5]. If the internal carotid artery although small in number, shows favorable results, espe­ is occluded and there is no cross-filling of the ipsilateral cially in the case of the vertebral artery, and no significant anterior and middle cerebral arteries from the contralateral complications. H,:s is mainly due to careful selection of carotid artery, the ipsilateral external carotid artery mw be cases and exclusion of potentially high-risk patients. This is the only source of perfusion of the cerebral hemisr: here. especially true in patient selection for vertebral artery angio­ Since the blood flow is through a number of small collateral plasty. Dilatation of a vertebral artery stenosis was never arteries, transluminal angioplasty of th e external carotid attempted if the diseased vertebral artery was the only artery in these cases does not bear a high risk of cerebral contributor to the basilar system circulation; neither was an emboli, thus offering an alternative to surgical end­ isolated vertebral artery dilated if it was feeding an isolated arterectomy. Although our case of external carotid artery posterior inferior cerebellar artery. stenosis was treated intraoperatively, we would attempt a Substantial experience in arterial dilatation is a prerequi­ percutaneous approach in treatment of nonulcerated ste­ site for any angiographer before attempting to dilate a nosis of the external carotid artery. The compli cations of vertebral artery stenosis. If catheterization of the vertebral transluminal angioplasty, including hematoma, arterial artery or insertion and advancing the guide wire within the thrombosis, distal emboli, and dissection, have been re­ vertebral artery is technically difficult, the procedure should ported by us [16] and others, but there were no complica­ be terminated. Dilatation of carotid stenoses bears a high tions during or after the procedures reported here. risk of cerebral emboli from an ulcerated plaque; however, ulcerated plaques are rarely seen in the vertebral artery. REFERENCES Stenotic lesions of the vertebral artery occur mainly at the origin of the artery and are nonulcerated. We consider 1. Gruntzig A, Hopff H. Perkutane Rekanalisation chronischer vertebral artery angioplasty only when the stenotic lesion is arterieller Verschlusse mit einem neuen Dilatationskatheter 174 MOTARJEME ET AL. AJNR:3, Marc hi April 1982

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