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Percutaneous Transluminal Angioplasty of the Brachiocephalic Arteries

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Percutaneous Transluminal Angioplasty of the Brachiocephalic Arteries 169 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.
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