Revascularization: Upper Extremity

Most of this chapter discusses management of occlusive disease of the subclavian and brachiocephalic arteries. Treatment of various conditions such as thoracic outlet syndrome and more distal lesions is also covered.

Subclavian and Brachiocephalic Disease

Symptomatic chronic ischemia of the upper extremity is commonly encountered in clinical vascular practice, comprising about 17% of symptomatic extracranial cerebrovascular disease ; 80% occurs in males. In contradistinction to chronic lower extremity ischemia, presenting symptoms in the upper extremity are often due to remote ischemia in the bed supplying collateral flow—namely, vertebral-subclavian and coronary-subclavian steal. However, ischemic symptoms of the upper extremity may occur with overutilization or hyperactivity of that extremity. This intimate association between the vascular territories of the arm, hindbrain, and heart (in post left internal mammary artery [LIMA] coronary artery bypass graft patients) is unique and may present technical challenges and potential complications not typically encountered in other vascular beds. With modern techniques and equipment, however, operators treating underlying stenotic or occlusive lesions of the proximal upper extremity arteries by interventional techniques can expect high degrees of success with low complication rates. ^, ^, ^,

Indications

Symptomatic chronic upper extremity ischemia
Symptomatic vertebral-subclavian steal syndrome
Symptomatic coronary-subclavian steal syndrome
Asymptomatic subclavian stenosis or occlusion in a patient about to undergo coronary artery bypass graft with LIMA engraftment
Preservation of dialysis or other vascular access

Contraindications

Asymptomatic disease (in general, except as noted earlier)
Renal insufficiency, severe aortic arch atherosclerosis (relative)

Equipment

6F to 9F sheaths, 45 and 90 cm, long enough to extend through the area of intervention from the access site; 4F to 5F sheaths may be employed when using retrograde radial access or brachial access.
Straight and angled hydrophilic wires
Diagnostic catheters of various shapes, such as Judkins right (JR)4 (Cordis Corp., Miami Lakes, FL), multipurpose, headhunter, LIMA, VTK (Cook Medical, Bloomington, IN), Amplatz (Boston Scientific, Natick, MA), Kumpe (Cook Medical), and Simmons (Merit Medical, Salt Lake City, UT)
Straight or angled-tip glide catheter
0.035-inch exchange wire, atraumatic, straight, or J tipped; 0.014-to 0.018-inch guidewires for low-profile systems
Balloons (including drug-eluting balloons) 4- to 10-mm diameter, 2 to 4 cm in length, with a long shaft length (110 cm long), if the site of access is from the femoral artery
Balloon-expandable stents (including drug-eluting stents) capable of achieving these diameters, and lengths from 20 to 40 mm
Covered stents in similar sizes for treatment of restenosis or for emergency use in vessel perforations
Coronary stents in 3.0, 3.5, and 4.0 mm for vertebral or LIMA salvage (with compatible 0.014-inch wire)

Technique

Anatomy and Approaches

Symptomatic disease of the left subclavian artery is roughly eight to ten times more frequent than in the brachiocephalic trunk or right subclavian artery. ^, This can be considered fortunate because intervention in the brachiocephalic or right subclavian artery naturally involves working close to the right common carotid artery, potentially subjecting it to embolization, dissection, ostial compression, or stent coverage.

Proper technique, as always, begins with case planning and selection of vascular access. The strength of the indications must be weighed against the relative contraindications (severe generalized arch disease, renal insufficiency, long occlusions) and operator experience for good case selection. Most complications will happen early in an operator’s experience in more difficult cases.

Aortoostial flush occlusions, long occlusions, and lesions close to the vertebral, right common carotid, or internal mammary artery (IMA) are all “yellow flags,” to be given thoughtful consideration.

The operator should select the vascular access point that yields the highest chance of success with the lowest risk of complication at both the access and intervention site. In general, this is femoral access. Brachial access should be considered first in cases with heavily diseased or tortuous iliofemoral vessels and in severely tortuous aortic arches, particularly those with flush occlusions. Brachial access is also often used when guidewire access cannot be gained in antegrade fashion from a first femoral approach. In such cases, retrograde passage of the guidewire is often surprisingly easy. More recently, retrograde radial access has been commonly employed.

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