Interventional Approaches for Peripheral Arterial Disease

Upper Extremity Disease

The innominate and subclavian arteries contribute the main blood supply to the upper extremities, but also provide flow to the brain via the carotid and vertebral arteries. In cases of coronary artery bypass grafting, they can also provide blood flow to the heart through a transposed internal thoracic (mammary) artery often referred to as a right or left internal mammary artery bypass. Symptoms of disease in the innominate or subclavian arteries generally present in the form of arm pain, coolness, or discoloration; alternatively, patients can also present with angina, cerebrovascular, and vertebrobasilar insufficiency, depending on the location of disease.

There are no randomized comparisons of surgical and percutaneous revascularization for occlusive diseases involving the aortic arch vessels. The use of percutaneous angioplasty and stenting continues to be a mainstay in the treatment for innominate and subclavian artery stenosis, unless contraindications of severe calcification exist, with patency rates and symptom relief being as high as 95%. Patency rates may be decreased when complete occlusion is encountered because these procedures are more technically difficult and require more manipulation, which can lead to increased complications such as stroke. Multiple surgical approaches for revascularization of arch vessels exist with variations in patency rates, some being as high as 98%. Percutaneous interventions are associated with vascular access and embolization complications, which can lead to further interventions, depending on location and severity. Dissection, thrombosis, and embolization involving the cerebrovascular arteries, internal thoracic artery, vertebral, and upper extremity territories are complications associated with both approaches and are uncommon.

Nonatherosclerotic pathologies can also affect the upper extremity vasculature and involve extrinsic compression of the subclavian or axillary artery or vein as it crosses the thoracic outlet. Thoracic outlet syndrome can involve the artery, vein, or nerve secondary to a cervical rib, fusion of the first and second rib, or repetitive motion trauma. The latter is most commonly seen in athletes and most commonly affects the vein (Paget-Schroetter syndrome). Surgical management is considered the definitive treatment, with decompression of the thoracic outlet by first rib resection. Catheter-directed thrombolysis can be used in the setting of venous thrombosis. Further endovascular intervention with stent placement is relatively contraindicated because it can lead to stent fracture or kinking secondary to continued extrinsic compression with resultant re-thrombosis. However, percutaneous intervention can be used after appropriate first rib resection.