Neurointervention.  2011 Aug;6(2):89-94. 10.5469/neuroint.2011.6.2.89.

The Use of Protection Device in Landmark-wire Technique of Symptomatic Subclavian Artery Occlusion with Combined Approach via Trans-femoral vs. Trans-brachial Arteries: Technical note

• Park S
• Kwak JH
• Baek HJ
• Park JW
• Kim JS
• Suh DC

• KMID: 1783989
• DOI: http://doi.org/10.5469/neuroint.2011.6.2.89

Abstract

PURPOSE
Since we reported about a landmark technique to reopen an occluded subclavian artery, we have faced difficulty in using protection devices in the vertebral artery to protect against thromboembolism from the reversed steal phenomenon after angioplasty and stenting. Therefore, we are presenting an optimal solution in using a protection device while recanalizing the occluded subclavian artery.
MATERIALS AND METHODS
Among 21 cases of stenting for subclavian artery steno-occlusion, we applied the landmark technique at the opposite end of an occluded segment in 4 patients and used a protection device in two patients. Because the embolic protection device was placed in the vertebral artery via the brachial artery, optimal angioplasty and stenting via the brachial route were limited. Therefore, angioplasty via the trans-brachial approach was needed to be followed by stenting through a trans-femoral approach. We estimated the safe and optimal steps for placement and retrieval of the protection devices in addition to stenting.
RESULTS
The procedure was safely performed when a stent was introduced via the femoral artery and a protection device was used via the brachial artery. However, in cases when a guidewire wasn't passed via the transfemoral route, simultaneous use of two systems via the brachial route could cause friction of devices or trapping of protection devices in a stent. When a protection device was trapped in a deployed stent, we retrieved the protection device with a 4F angiocatheter by selectively rotating the catheter tip. To avoid such procedural difficulty, we recommend using a transbrachial angioplasty followed by trans-femoral stenting while placing the protection device in the vertebral artery via the trans-brachial route.
CONCLUSION
If a guidewire is not passed through using a trans-femoral approach while performing the landmark technique, changing the stenting route from brachial to the femoral artery can be useful after securing the lumen in the occluded subclavian artery after angioplasty via the brachial artery.

Keyword

Subclavian artery; Stents; Endovascular techniques; Embolic Protection; Devices

MeSH Terms

Angioplasty
Brachial Artery
Catheters
Embolic Protection Devices
Endovascular Procedures
Femoral Artery
Friction
Humans
Stents
Subclavian Artery
Thromboembolism
Vertebral Artery

Figure

• 

  Fig. 1 A 64-year-old male patient presented with dizziness and left arm weakness. He had history of laryngeal cancer which was operated and radiated 12 years ago.A. Angiogram obtained through both catheters introduced via the trans-femoral and trans-brachial routes reveals the occluded left subclavian artery.B. The protective device is trapped in the stent strut while deploying the stent via the same trans-brachial route and is retrieved by 4 F Davis angiocatheter.C. The final angiogram reveals good patency of the recanalized SCA. Note good antegrade flow in the vertebral artery and mild spasm at the vertebral artery ostium.

• 

  Fig. 2 (Modified from reference 9). Procedure diagram of the Landmark-wire technique using a protective device as well as angioplasty balloon via the brachial artery (A) A guidewire passes through the occluded segment via the trans-brachial route. Not a protection device deployed via the same route. (B) Angioplasty is performed via transbrachial route with a protective device in the vertebral artery. Final stenting procedure is performed via transfemoral route (not shown).

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