Cerebral Ischemic Complications of Subclavian Artery Stenting: Relationship between Lesion Location and Procedural Strategy

Abstract

Objective: Clinical research demonstrating safety and security in subclavian artery stenting (SAS) is limited because treatment strategies for SAS vary greatly among institutions, operators, and clinical conditions, as no standard protocol exists. As stenotic lesions frequently occur in the proximal portion of the subclavian artery (SA), it is often difficult to stabilize the guiding catheter for stent delivery. Our purpose was to assess whether lesion location can be used to predict optimal procedural strategies. Methods: We performed a retrospective, single-center observational study on 26 consecutive patients who underwent SAS between 2004 and 2016. We categorized patients treated with SAS into two groups according to lesion location: those with lesions located less than 10 mm from the origin of the SA (Group P) and those with lesions in the distal portion (Group D). We defined a bidirectional approach via both brachial and femoral puncture as well as bilateral brachial puncture as combined access. In pull-through method, a guidewire was passed from one sheath to another. We compared Group P with Group D in terms of procedural strategy and efficacy. Results: All 26 cases were clinically successful. Asymptomatic cerebral embolism was found in 10 (48%) of 21 cases in which postoperative MRI was performed, and the number of spotty lesions was less than four in every patient. Arterial access-site complications were documented in eight patients. Two cases of late in-stent restenosis were retreated with balloon dilatation. Cases with retrograde ipsilateral vertebral artery (VA) blood flow and symptomatic lesions occurred more frequently in Group P than in Group D (79% vs. 42%; p = 0.06, 71% vs. 33%; p = 0.05, respectively). Patients in Group P were significantly more often treated with combined access (100% vs. 42%; p = 0.001), with the pull-through method (64% vs. 0%; p < 0.001) than those in Group D. The distal end of the stent was involved with the ipsilateral VA orifice more often in Group D than in Group P (50% vs. 7%; p = 0.02). Conclusion: These results demonstrate that our strategy is a safe and effective method of stenting for SA stenosis in the portion of the artery that is proximal to the aorta. We should pay special attention to the risk of arterial access-site complications.