J Cerebrovasc Endovasc Neurosurg.  2015 Mar;17(1):27-31. 10.7461/jcen.2015.17.1.27.

Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary Artery Bypass Grafting Due to Right Subclavian Artery Origin Stenosis

• Sakamoto S
• Kiura Y
• Okazaki T
• Ichinose N
• Kurisu K

• KMID: 1963146
• DOI: http://doi.org/10.7461/jcen.2015.17.1.27

Abstract

Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA). Subclavian artery (SA) stenosis proximal to the ITA graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right SA origin stenosis after CABG. A 64-year-old man with a history of CABG using the right ITA presented with exertional right arm claudication. Angiogram showed a CSS and retrograde blood flow in the right vertebral artery (VA) due to severe stenosis of the right SA origin. Endovascular treatment of the right SA stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the SA proximal to the origin of the right VA and ITA through the right brachial artery approach and distal filter protection of the right internal carotid artery (ICA) through the left femoral artery (FA) approach were performed. Endovascular stenting for SA stenosis from the right FA approach was performed under cardiac and cerebral protection by filter-protection of the ICA and balloon-protection of the VA and ITA. Successful treatment of SA severe stenosis was achieved with no complications.

Keyword

Endovascular procedures; Stenosis; Stent; Subclavian artery; Subclavian steal syndrome

MeSH Terms

Arm
Brachial Artery
Carotid Artery, Internal
Catheters
Constriction, Pathologic*
Coronary Artery Bypass*
Endovascular Procedures
Femoral Artery
Humans
Mammary Arteries
Middle Aged
Stents*
Subclavian Artery*
Subclavian Steal Syndrome*
Transplants
Vertebral Artery

Figure

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  Fig. 1 (A) Computed tomography angiography shows severe stenosis with calcification in the right subclavian artery origin (arrow) and poor visualization of the right internal thoracic artery graft (arrowheads). (B) Left vertebral angiography shows retrograde blood flow in the right vertebral artery.

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  Fig. 2 (A) Preoperative angiography shows 90% stenosis in the right subclavian artery origin (arrow). (B) The filter-wire (arrow) is deployed into the right internal carotid artery through the 4-Fr femoral sheath. A 5.2-Fr occlusion balloon catheter is navigated into the subclavian artery proximal to the origin of the right vertebral artery and internal thoracic artery through the right brachial sheath, and is then inflated (double arrows). (C) The 7 × 27 mm balloon-expandable stent is deployed to the subclavian artery origin stenosis (asterisk). (D) Postoperative angiogram shows excellent dilatation.

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  Fig. 3 (A) Follow-up computed tomography (CT) angiography at 3 months shows stent deployment in the right subclavian artery origin (asterisk) and good visualization of the right internal thoracic artery graft (arrowheads). (B) Follow-up CT angiography at 3 months shows a good patency of the stent in the subclavian artery (arrow).

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