Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists.

Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes.

Coil Embolization of Tributaries of Brachiocephalic Fistula is Effective in the Management of Vascular Steal.

BACKGROUND: To determine if an aggressive approach to occlude all or majority of the tributaries of the cephalic vein is effective in eliminating signs and symptoms of vascular steal in patients with brachiocephalic fistula. METHODS: Retrospective chart review over a 15-month period of all patients managed with coil embolization of tributaries of brachiocephalic fistulae. RESULTS: A total of 19 patients (11 females, age 65 ± 9.7 years), presented with signs and symptoms of vascular steal. All patients had a brachiocephalic fistula with a 6.3 month average fistula age. Overall, a total of 111 coils were used to occlude 42 tributaries. Two patients had concomitant surgical ligation of 3 tributaries. Postoperative pain at the site of coiled tributaries was reported by two patients. A single patient suffered a major postprocedure complication (delayed hypotension), requiring hospital admission. All but one patient had significant improvement in symptoms of vascular steal postintervention. CONCLUSIONS: An aggressive approach to coil embolization of all major tributaries of a brachiocephalic fistula is effective in eliminating signs and symptoms of vascular steal.

Long-term Outcome of Axillo-axillary Bypass in Patients with Subclavian or Innominate Artery Stenosis.

BACKGROUND: Subclavian or innominate artery stenosis (SAS) may cause upper extremity and cerebral ischemia. In patients with symptomatic subclavian or innominate artery stenosis, percutaneous transluminal angioplasty is the treatment of first choice. When percutaneous transluminal angioplasty is technically restricted or unsuccessful, an extrathoracic bypass grafting, such as an axillo-axillary bypass can be considered. The patency rate of axillo-axillary bypass is often questioned. The aim of this study was to assess long-term outcomes of patients undergoing axillo-axillary bypass for subclavian or innominate artery stenosis (SAS) and to provide a literature overview. METHODS: In this single-center study, data from patients who underwent axillo-axillary bypass for symptomatic SAS between 2002 and 2018 were retrospectively analyzed. Bypass material was Dacron® (54%) or polytetrafluoroethylene (PTFE) (46%). Primary outcome was graft patency and secondary outcome was the occurrence of mortality and stroke. In addition, a systematic literature search was performed in MEDLINE and EMBASE databases including all studies describing patency of axillo-axillary bypass. RESULTS: In total, 28 axillo-axillary bypasses had been performed. Cumulative primary, primary-assisted, and secondary patency rates at one year were 89%, 93%, and 96%, respectively. Cumulative primary, primary-assisted, and secondary patency rates at five years were 76%, 84%, and 87%, respectively. The primary-assisted patency rates at five years for Dacron® and PTFE were 93% and 73%, respectively. A total of four primary axillo-axillary bypass occlusions occurred (14%), with a mean of 12 months (range, 0.4-25) after operation. The 30-day mortality was 7%; one patient died after a stroke and one died of a myocardial infarction. At the first postoperative follow-up control, 22 of the 26 remaining patients (85%) had relief of symptoms. The literature search included 7 studies and described a one-year primary patency range of 93-100% (n = 137) and early postoperative adverse events included death (range, 0-13%) and stroke (range, 0-5%). CONCLUSIONS: Patency rates of axillo-axillary bypasses for patients with a symptomatic SAS are good. However, the procedural complication rate in this series is high and attention should be paid to intervention indication.

Innominate to contralateral brachial artery bypass via ministernotomy with anatomic tunneling for critical ischemia of the left upper extremity.

OBJECTIVES: Scarring from prior bypass surgery and irradiation may compromise revascularization options in critical ischemia due to underlying occlusive disease. Occlusive disease of the axillo-brachial artery is particularly difficult to revascularize under such hostile conditions. METHOD: We present a case of a 58-year-old woman presenting with a painful, pulseless, and cool left upper extremity. The patient had a known history of left upper extremity occlusive disease which was managed by subclavian-axillary artery stenting with re-occlusion and subsequent extra-anatomic left carotid-to-proximal brachial artery prosthetic bypass, which was complicated by stroke. The patient had a history of left mastectomy, axillary node dissection, and external beam radiation therapy. When considering revascularization options, the combination of post-radiation changes and scarring of the conventional operative zones for revascularization posed a high risk for complications. We describe a novel approach for such revascularization, where the inflow source was the terminal brachiocephalic artery, outflow to the upper left brachial artery, with anatomic intrathoracic-to-axillary tunneling through the thoracic outlet after verifying the lack of dynamic extrinsic compression at that level. RESULT: The procedure resulted in resolution of the symptoms and the patient continued to do well 2 years later. CONCLUSION: This case shows that anatomic tunneling through the thoracic outlet can be a viable option for upper extremity revascularization when hostile conditions preclude other anatomic tunneling routes or extra-anatomic options.

Use of a Dual-Filter Embolic Protection Device for Brachiocephalic Artery Stenting.

A 77-year-old female with peripheral artery disease underwent brachiocephalic artery stenting for right upper extremity claudication. Given a very high atherosclerotic burden seen on CT, a dual-filter embolic protection device (Sentinel, Boston Scientific) was deployed from the right radial artery to protect the right common carotid and subclavian arteries, and therefore the vertebral artery, during the stenting procedure. This case report demonstrates a novel use of this dual-filter device to provide both carotid and vertebral artery embolic protection during brachiocephalic artery intervention.

Stenting for Innominate Artery Stenosis Under Double-Filter Protection of the Anterior and Posterior Circulation via the Right Brachial Artery.

Several protocols for angioplasty and stenting for stenosis of an innominate artery (IA) are reported, but the protocols are sometimes complicated and have disadvantages. We report a case of IA stenosis presenting ischemic symptoms in a 58-year-old woman. Stenting for the IA stenosis was performed through the right femoral artery. The cerebral protection was placed via the right brachial artery, with a filter at the right internal carotid artery and another filter at the right vertebral artery. The symptomatic IA stenosis was resolved without any complications. Regardless of the direction of blood flow, simultaneous protection of both the anterior and posterior cerebral circulation is necessary during IA stenting. Double-filter protection can provide excellent cerebral protection during an IA stenting procedure.

Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.

OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Anomaly in the Embryogenesis of the Aorta associated with Subclavian Steal Phenomenon.

Congenital aortic arch anomalies are rare and may be associated with other congenital cardiovascular malformations. The authors report a rare case of anomaly in the aortic arch embryogenesis, presenting with a right aortic arch and an isolated innominate artery, associated with the subclavian steal phenomenon. This condition is discussed considering the Edwards hypothetical double embryonic arch and its clinical aspects.

Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting.

PURPOSE: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. MATERIALS AND METHODS: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. RESULTS: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2-month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. CONCLUSION: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Degradation of Glycocalyx and Multiple Manifestations of Endothelial Dysfunction Coincide in the Early Phase of Endothelial Dysfunction Before Atherosclerotic Plaque Development in Apolipoprotein E/Low-Density Lipoprotein Receptor-Deficient Mice.

Background The impairment of endothelium-dependent vasodilation, increased endothelial permeability, and glycocalyx degradation are all important pathophysiological components of endothelial dysfunction. However, it is still not clear whether in atherosclerosis, glycocalyx injury precedes other features of endothelial dysfunction or these events coincide. Methods and Results Herein, we demonstrate that in 4- to 8-week-old apolipoprotein E/low-density lipoprotein receptor-deficient mice, at the stage before development of atherosclerotic plaques, impaired acetylcholine-induced vasodilation, reduced NO production in aorta, and increased endothelial permeability were all observed; however, flow-mediated dilation in the femoral artery was fully preserved. In 4-week-old mice, glycocalyx coverage was reduced and endothelial stiffness was increased, whereas glycocalyx length was significantly decreased at 8 weeks of age. Early changes in endothelial function were also featured by increased plasma concentration of biomarkers of glycocalyx disruption (endocan), biomarkers of endothelial inflammation (soluble vascular cell adhesion molecule 1), increased vascular permeability (angiopoietin 2), and alterations in hemostasis (tissue plasminogen activator and plasminogen activator inhibitor 1). In 28-week-old mice, at the stage of advanced atherosclerotic plaque development, impaired NO production and nearly all other features of endothelial dysfunction were changed to a similar extent, compared with the preatherosclerotic plaque phase. The exceptions were the occurrence of acetylcholine-induced vasoconstriction in the aorta and brachiocephalic artery, impaired flow-mediated vasodilation in the femoral artery, and further reduction of glycocalyx length and coverage with a concomitant further increase in endothelial permeability. Conclusions In conclusion, even at the early stage before the development of atherosclerotic plaques, endothelial dysfunction is a complex multifactorial response that has not been previously appreciated.

Innominate artery bifurcation pseudoaneurysm repair by "kissing stent-grafts technique": a case report.

BACKGROUND: We introduce the "kissing stent-grafts technique" for a patient who suffered from a pseudoaneurysm in bifurcation of innominate artery. This technique repaired an innominate artery bifurcation pseudoaneurysm; it successfully isolated the pseudoaneurysm and preserved both right subclavian and right common carotid artery. CASE PRESENTATION: A 60-year-old Asian (Chinese) woman complained of discovering a cervical pulsatile mass. A pseudoaneurysm at the location of innominate artery bifurcation is a rare and difficult situation that should be treated by vascular surgeons. To our knowledge, this is the first case to use the "kissing stent-grafts technique" in treating innominate bifurcation pseudoaneurysm. With this minimally invasive endovascular treatment, our patient avoided open surgery and recovered quickly. CONCLUSIONS: When treating vascular lesions with complicated anatomy, endovascular treatment always has the merit of being minimally invasive. "Kissing stent-grafts technique" can be useful in locations other than coronary and aortic bifurcation.

Aorta-innominate bypass through ministernotomy.

Atherosclerotic innominate artery occlusive disease can lead to cerebral and upper extremity ischemia. Innominate artery angioplasty and stenting can be complicated by stent fractures and restenosis; furthermore, this technique is limited in treatment of innominate artery occlusions. Ministernotomy to the second or third intercostal space can be used instead of conventional full sternotomy for open surgical revascularization of the innominate artery with excellent perioperative and long-term outcomes. This series of three consecutive patients highlights the technique of aorta-innominate artery bypass through ministernotomy.

Axillo-Axillary Artery Bypass With Coil Embolization of the Innominate Artery for a Traumatic Innominate Artery Aneurysm: A Case Report.

BACKGROUND: Innominate artery aneurysm (IAA) is a rare cervical artery aneurysm. Although atherosclerosis is its most common cause, IAAs due to cervical injury are often reported. Operative indications for IAAs include rupture or symptomatic aneurysm, saccular aneurysm, aneurysm with a diameter of 3 cm or greater, and aneurysmal change of the origin of the innominate artery. Although the ligature of the innominate artery or open surgical repair is well described, the usefulness of endovascular repair has also recently been reported. Herein, we report a case of traumatic IAA with infection in the cervical region after tracheostomy. CASE PRESENTATION: A 40-year-old man with cholecystolithiasis planned to undergo laparoscopic cholecystectomy at another hospital. Urgent tracheostomy was performed because of laryngeal edema at the induction of general anesthesia. Enhanced computed tomography angiography 1 week after the tracheostomy revealed a saccular IAA. The patient was deemed to be at high risk for aneurysm rupture and was referred to our hospital. Preoperative Matas test, Allcock test, and innominate arterial stump pressure measurement were performed to assess the cerebral blood flow and ischemic tolerance of the brain. These examinations showed the patency of the circle of Willis. An axillo-axillary artery bypass with coil embolization of the innominate artery was performed to avoid postoperative vascular graft infection. No postoperative complications such as infection or cerebral infarction occurred. Magnetic resonance imaging angiography performed 6 months after surgical treatment showed that the aneurysm had disappeared, and patency of the bypass graft was present. There were no postoperative complications, such as neurological deficits or graft infection, at more than 5 years after surgery. CONCLUSIONS: We report a successfully treated case of IAA after tracheostomy. Axillo-axillary artery bypass with coil embolization of the innominate artery is an effective treatment of IAA with cervical infection.

Selective Cerebral Perfusion with the Open Proximal Technique during Descending Thoracic or Thoracoabdominal Aortic Repair: An Option of Choice to Reduce Neurologic Complications.

PURPOSE: Selective cerebral perfusion with the open proximal technique for thoracoabdominal aortic repair has not been conclusively validated because of its procedural complexity and unreliability. We report the clinical outcomes, particularly the cerebroneurological complications, of an open proximal procedure using selective cerebral perfusion. METHODS: A retrospective chart review identified 30 patients between 2007 and 2015 who underwent aortic repair through left lateral thoracotomy with selective cerebral perfusion, established through endoluminal brachiocephalic and left carotid artery and retrograde left axillary artery. RESULTS: The mean durations of the open proximal procedure and cerebral ischemia (the duration of the open proximal procedure minus the duration of selective cerebral perfusion) were 110.3 ± 40.1 min and 24.8 ± 13.0 min, respectively. There were two cases (7%) of permanent neurologic dysfunction (PND) but no in-hospital deaths. Multivariate analysis identified the duration of cerebral ischemia as an independent risk factor for neurologic complications including temporary neurologic dysfunction (TND; odds ratio (OR): 1.13; p = 0.007), but no correlation was found between selective cerebral perfusion duration and neurologic complications. CONCLUSION: Despite the relatively long duration of the open proximal procedure, selective cerebral perfusion has a potential to protect against cerebral complications during thoracic aortic repair through a left lateral thoracotomy.

Bovine aortic arch: clinical significance and hemodynamic evaluation.

OBJECTIVE: The most common aortic arch branching variation described in literature is the common origin of the brachiocephalic trunk and left common carotid artery ("bovine arch" / type II aortic arch), with an incidence of 7.2-21.1%. The first aim of this study was to investigate the prevalence of bovine arch in the fetuses. The second aim was the hemodynamic evaluation of the epiaortic vessels. METHODS: In two years we examined 742 pregnant women and it was possible to obtain a good hemodynamic evaluation in 39 patients. Among the 39 fetuses, we found 6 with bovine arch. The blood flow of all epiaortic vessels and of MCA was evaluated. RESULTS: Among the 742 fetuses examined, the bovine aortic arch was identified in 45 patients (6.06%). The hemodynamic evaluation of the epiaortic vessels showed statistically significant differences between the bovine arch and normal aortic arch. CONCLUSION: The presence of bovine aortic arch in the fetus is characterized by some hemodynamical differences. They could have a possible relationship with the incidence of some pathologies in adult life. Prenatal knowledge of anatomic variants of the aortic arch can bring benefits to the individual's health for future possible cardiovascular investigations.

Brachiocephalic Arterial Occlusive Disease Presenting as Limb-Shaking Transient Ischemic Attacks.

Limb-shaking transient ischemic attacks (LSTIAs) are a phenomenon that occurs due to transient hypoperfusion to a cerebral motor territory with a chronically outstripped autoregulatory vascular reserve. First described in 1962 by Miller Fisher, the pathogenesis and the global understanding of this presentation have undergone a significant advancement throughout the years. Typically, patients will present with this syndrome of transient hypoperfusion in the context of extracranial carotid intrinsic vessel stenosis or by intracranial vascular stenosis to select motor pathways. We present within this case report a novel mechanism by which LSTIAs may emerge. Through this knowledge, clinicians may need to consider expansion of their diagnostic breadth to include proximal vasculature luminal integrity.

Determinants of long-term outcome in patients after percutaneous stent-assisted management of symptomatic subclavian or innominate artery stenosis or occlusion.

AIMS: Incidence and determinants of restenosis and adverse events after endovascular management (PTA±stent) of the subclavian/innominate artery (SA/IA) stenosis/occlusion remain unclear due to the relatively short-term follow-up or limited size of prior studies. This large-scale, long-term prospective study investigated safety, efficacy, and prognosis after SA/IA PTA±stent. METHODS AND RESULTS: The study involved 411 consecutive patients with symptomatic SA/IA stenosis/ occlusion; 393 were followed annually after successful PTA±stent for up to 16 (minimum one) years. Primary outcomes were freedom from restenosis and MACCE (cardiovascular death, myocardial infarction, stroke). Angiographic success rate was 99.7% in stenoses and 76.1% in occlusions. The incidence of any periprocedural complication was 4.4% (serious - 1.2%). Symptoms of limb ischaemia, vertebrobasilar insufficiency or angina resolved in 79.1%, decreased in 19.6%. Freedom from restenosis was 82.6% and 77.9% whereas freedom from MACCE was 86.6% and 78.3% at five and 10 years, respectively. MACCE determinants (HR; 95% CI) were previous myocardial infarction (5.36; 2.9-9.91), ischaemic stroke (2.03; 1.12-3.66), hs-CRP (1.04; 1.02-1.07), concurrent atherosclerosis (1.35; 1.00-1.82). Restenosis determinants were implantation of ≥2 stents (2.65; 1.23-5.72), stent diameter (0.45; 0.34-0.59), hs-CRP (1.06; 1.02-1.1), WBC (1.2; 1.07-1.35), age (0.97; 0.94-0.99), concurrent carotid or vertebral disease (1.85; 1.07-3.18), IA intervention (2.28; 1.08-4.84). CONCLUSIONS: This study established long-term durability of stent-assisted PTA of symptomatic SA/IA disease and identified risk factors for restenosis and long-term MACCE. Patients at increased risk might benefit from targeted, intensified prevention measures.

An Alternative Technique for Hemiarch Replacement Without Using Deep Hypothermic Circulatory Arrest.

We describe an alternate technique to perform a replacement of the aortic hemiarch without the need for hypothermic circulatory arrest by axillary cannulation and arch vessel isolation. In 2015, 3 patients underwent hemiarch reconstructions for ascending aortic aneurysms that extended into the arch. Each was performed using right axillary cannulation, isolation and clamping of the innominate artery with isolation, and tangential clamping of the aorta distal to the innominate. There were no neurologic events and no perioperative morbidity or mortality.

Transcarotid Approach for Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis.

BACKGROUND: To evaluate the hybrid treatment of severe stenosis or occlusion of the proximal innominate artery (IA) and common carotid artery (CCA) via surgical cutdown of the CCA and distal clamping for cerebral protection against thromboembolic events during retrograde stenting. METHODS: Consecutive patients undergoing retrograde stenting of proximal IA and CCA stenosis or occlusion via surgical cutdown of the CCA and with distal clamping for prevention of embolization, with or without concomitant endarterectomy of the carotid bifurcation, between April 1999 and August 2015 were reviewed. Perioperative and long-term outcomes were assessed. RESULTS: Thirty-five patients underwent a total of 36 successful interventions. One patient underwent staged bilateral stenting. Additional concomitant carotid endarterectomy was performed in 13 patients (36%). No new neurological symptoms neither perioperatively nor in-hospital were recorded. Thirty-day follow-up revealed 1 new ipsilateral and 1 new contralateral stroke (6%) with completely patent stents, no reinterventions, and 2 unrelated deaths (6%). Median follow-up was 56 months (range: 1-197). After 5 and 10 years, the Kaplan-Meier estimated overall survival rate was 85% and 52%. Primary assisted patency rate was 94% during follow-up. Overall freedom from reintervention was 91%. Three reinterventions were performed during the first postoperative year. Three new neurological events occurred during follow-up, 1 ipsilateral (3%) and 2 contralateral (6%). The ipsilateral event occurred during the first year and both contralateral events during the second year postoperatively. CONCLUSIONS: The retrograde hybrid approach to proximal IA and CCA disease is a safe procedure with surgical outflow control preventing perioperative stroke in ipsilateral carotid territory. Most relevant in-stent stenoses/occlusions and new neurological events occurred within the first 2 years, suggesting these patients should undergo regular monitoring early postoperatively. High patency rates without further neurological events can be expected thereafter.