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Innominate artery occlusion

endovascular
by

mohamed ramadan

on 9 December 2012

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Transcript of Innominate artery occlusion

Epidemiology INNOMINATE ARTERY OCCLUSION 1.5% to 2.0% of general population Shadman ,2004 Anatomy Aetiology Atherosclerosis
Takayasu’s arteritis
Radiation-induced injury
Aneurysm
Dissection Imaging Duplex
CTA
MRA
Catheter arteriography
TEE
MOHAMAD RAMADAN M.Sc. Vascular Surgeon

Sahel Teaching Hospital Background Occlusive disease of the arch vessels can have a dramatic impact on the patient Neurologic consequences , Loss of the ability to use the upper extremities to perform basic tasks and inability to simply monitor blood pressure Surgical revascularization with a prosthetic graft (DeBakey 1958) or endarterectomy (Carlson 1977) Surgery gives excellent results, but technical skills are required and the potential need to deal with problems related to intraoperative misadventure This stimulated search for a less invasive method to treat these patients About 5% to 15% of carotid artery disease patients are found to have disease in the arch vessels Long, 2001 4% to 7% of patients with coronary artery disease Osborn , 2002 Most of the disease in these vessels occurs in the left subclavian artery, with less than 30% affecting the innominate artery and a similar percentage affecting the left common carotid artery Mostly 3 arch vessels are known 20 % bovine arch with only 2 arch vessls 6% 4 arch vessels Treatment options Surgical
Endovascular
Hybrid Surgical Treatment Endovascular Endovascular interventions in the arch vessels consisted of small numbers of patients treated with angioplasty and limited follow-up

Endovascular therapy has gained widespread acceptance as the primary form of therapy for occlusive disease of the arch vessels ANATOMIC LESIONS FAVORABLE TO INTERVENTION
Stenosis
Concentric lesions
Nonostial lesions
Lesions with vessel origin distal in the arch
Noncalcified lesions
Nonulcerated lesions ANATOMIC LESIONS UNFAVORABLE TO INTERVENTION
Occlusion
Eccentric lesions
Lesions with proximal rotation of the vessel origin
Calcification
Ulceration
Symptomatic lesions
Lesions near the vertebral artery origin Angioplasty Initial descriptions of endovascular interventions in the supraaortic trunks involved angioplasty alone In the majority of these patients, initial success rates were in the range of 80% to 95% Przewlocki, 2006 Recurrence rates were acceptable and varied from 8% to 25% at 1 to 2 years in those in whom immediate technical success was achieved Brountzos, 2004 Stenting The introduction of stents for treating arch vessel occlusive disease began in the 1990s, and they have become the primary mode of therapy for most surgeons Technical success rates from 91% to 100%
Patency rates of 77% to 100% over an 18- to 24-month period
It appears that when treating occlusions or complex stenoses, primary stenting should be the preferred approach
Schillinger, 2001 DES limited repoprted use
Boulos , 2005
Covered stents : it seems lowering myointimal hyperplasia and recurrence rates but no available data render it recommended
Ewings, 2008 Patency rates appear to be lower than reported for surgical reconstruction
One-year patency rates vary from 88.5% to 97%, and 5-year patency rates vary from 77% to 89%. Rodriguez-Lopez
36-month secondary patency rate of 90%, which is comparable to data from surgical bypass series Anatomical (transthoracic)
Preferred for good-risk patients with multivessel disease
Aorto-carotid and aorto-subclavian bypass
Endarterectomy of innominate artery
Prefabricated branched graft is ideal if extensive atheromas in the arch Extra-anatomical (cervical)
ideal for single-vessel subclavian disease or for patients at prohibitive
risk for median sternotomy
Carotid-subclavian bypass
Carotid-subclavian transposition
Carotid –carotid bypass
Axilloaxillary and Subclavian-Subclavian Bypass
Carotid – contralateral Subclavian bypass Crawford and coworkers:
direct brachiocephalic revascularization (combining endarterectomy and bypass) in 1962 and reported a 30-day mortality of 7.5%

In 1983, these authors reported their own series of brachiocephalic revascularization, with stroke and 30-day mortality rates of 6.9% and 4.7%, respectively Kieffer and coauthors:
reported 2.9% stroke, 1.5% myocardial infarction, and 5.2% mortality rates
5- and 10-year patency rates of 98.4% and 96%, respectively

Rhodes and colleagues :
Reported 7% stroke, 3% myocardial infarction, and 3% mortality rates, with a 5-year patency rate of 80%

Berguer and associates:
reported 8% stroke, 3% myocardial infarction, and 8% mortality rates, with 5- and 10-year patency rates of 94% and 88%, respectively 56 y F
Pain induced by effort in Rt UL and dizziness
No DM
No smoking
No cardiac history
No previous strokes No Rt radial or brachial pulsations
Normal labs Innominate artery occlusion
50% stenosis in proximal ICA
Reversed flow in Rt Vertebral artery
Lt Subclavian artery stenosis Duplex Procedure Access:
Duplex guided Rt trans-brachial, Rt trans-femoral Arteriography:
Brachial defined end of occlusion
Femoral defined arch anatomy Crossing:
By 0.035 GW through brachial access then placed at proximal arch Tretement:
No predilataion
Stent with balloon mounted chosen at exact diameter determined by Duplex for higher radial force and optimum placement
No post dilatation
No flaring
Genesis 8X39 mm Completion angiography
Post operative Duplex showed normalization of velocities Medications:
Periprocedural double antiplatelets
Intra-procedural heparin THANK YOU case presentation Planning Treating innominate occlusion
No treatment for both ICA and Subclavian lesions
No EPD
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