Keywords
endovascular - through-and-through access - left subclavian artery recanalization
Introduction
Through-and-through wire technique for endovascular interventions is commonly used
for endovascular aortic and peripheral interventions.[1]
[2] The purpose of this report was to enhance this literature and suggest an alternative
pathway to recanalization of an occluded vessel/stent and precise angioplasty and/or
placement of a stent.
Case Presentations
Case 1
A 67-year-old female patient with medically managed dyslipidemia and hypertension
presented for evaluation for new left upper extremity tiredness, heaviness, and pain
with activity. Cross-sectional imaging in the form of computed tomography angiography
(CTA) and three-dimensional reconstruction demonstrated an occlusion of the left subclavian
artery (LSCA) ([Fig. 1]). Recanalization of the LSCA was initiated through a left brachial artery approach.
However, there was inability to assure whether the soft-angled glidewire was traversing
the true lumen or a subintimal plane of this vessel. Therefore, access was gained
through the left common femoral artery (LCFA), and in a retrograde fashion through
the aorta, the stump of the LSCA was probed with a second glidewire and recanalization
of the LSCA was facilitated. Once access through the true lumen of the LSCA was achieved,
the glidewire from the LCFA was used to probe the tip of the Kumpe catheter from the
left brachial artery, and by traversing this catheter, we obtained through-and-through
access from the left brachial to the LCFA ([Fig. 2A]). With this through-and-through wire in place, precise deployment of a 6-mm covered
iCast (Atrium Medical Corporation, Merrimack, NH) stent ([Fig. 2B]) was facilitated without risking coverage of the left vertebral artery by gently
tugging from each end at the through-and-through wire.
Fig. 1 Computed tomography angiography three-dimensional reconstruction of the aorta and
the left subclavian artery occlusion (white arrow).
Fig. 2 (A) Accessing of the glidewire into the lumen of the Kumpe catheter through the left
brachial artery (white arrow) coming from the left common femoral artery and (B) angiogram of the already deployed 6-mm iCast covered stent in the left subclavian
artery (white arrow depicts the left vertebral artery).
Case 2
A 72-year-old female patient with a previously failed LSCA stent and left carotid
to subclavian artery bypass presented for evaluation for new left upper extremity
tiredness and a syncopal episode. CTA demonstrated an occlusion of the LSCA stent
and left carotid to subclavian artery bypass ([Fig. 3]). Recanalization of the LSCA stent was performed through a left radial artery and
LCFA approach. In this instance, a stiff guide catheter was placed right at the origin
of the LSCA stent and using the back end of the glidewire access was obtained into
the LSCA ([Fig. 4A]). Again, through-and-through access from the left radial to the LCFA was obtained
and the LSCA stent was angioplastied ([Fig. 4B]).
Fig. 3 Curved reformat computed tomography angiography with maximal intensity projections
at 8 mm demonstrates occluded left subclavian artery stent (white arrow) and occluded
left common carotid artery to subclavian artery bypass graft (curved black arrow).
The left subclavian artery (black arrow) is predominately supplied by retrograde flow
as seen at the left vertebral artery origin (black arrowhead).
Fig. 4 (A) The stiff end of the glidewire (white arrow) was used to cross the occluded left
subclavian artery stent with the support of a stiff guide catheter from the left common
femoral artery approach. (B) Once through-and-through access from the left radial artery to the left common femoral
artery was obtained, the stent in the left subclavian artery was angioplastied.
Discussion
Ischemic stroke is one of the leading causes of death and long-term disability worldwide.[3] Carotid stenosis is responsible for a 2% risk of stroke per year. We present this
case of rapid progression of disease in a patient who would not, under the current
guidelines, have been subject to routine carotid screening.[1] Furthermore, it presents with intraplaque hemorrhage, a marker for high risk of
stroke and plaque progression.[4] This case illustrates the value of additional imaging studies in patients who demonstrate
atherosclerosis detected by screening ultrasound. CTA is widely available, relatively
inexpensive, and specific for detection of cervical internal carotid artery stenosis.
Magnetic resonance angiography (MRA) with vessel wall imaging is increasingly utilized
to better characterize carotid plaques to identify vulnerable lesions especially with
borderline luminal stenosis. MRA is the imaging modality of choice to best detect
intraplaque hemorrhage,[5] which is known to correlate with subsequent ischemic cerebrovascular events.[4]
