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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 1  |  Page : 47-49

Trans-femoral-brachial (combined) approach for the percutaneous angioplasty of eccentric stenosis and unfavorable takeoff origin of the right brachiocephalic artery – “Entry from the back door”


Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Web Publication10-May-2019

Correspondence Address:
Dr. Pankaj Jariwala
Yashoda Hospitals, Somajiguda, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_2_19

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  Abstract 


Right brachiocephalic stenoses are usually discrete short-segment lesions, but sometimes, they are the most difficult to intervene for certain reasons. Their takeoff from the arch of the aorta and eccentricity of the stenotic lesion may pose problems while intervention. Furthermore, there is an controversy for the use of distal protection device during angioplasty. There are many methods described for its interventions, but transbrachial access is easier to tackle difficulties those may arise with transfemoral approach. We describe a case of right brachiocephalic high-grade stenosis, which was difficult to access by transfemoral approach, but transbrachial access solved our problem, and we could deploy the stent across the lesion with ease.

Keywords: Brachiocephalic trunk, innominate artery, peripheral angioplasty, peripheral stents, transbrachial access


How to cite this article:
Jariwala P. Trans-femoral-brachial (combined) approach for the percutaneous angioplasty of eccentric stenosis and unfavorable takeoff origin of the right brachiocephalic artery – “Entry from the back door”. J Indian coll cardiol 2019;9:47-9

How to cite this URL:
Jariwala P. Trans-femoral-brachial (combined) approach for the percutaneous angioplasty of eccentric stenosis and unfavorable takeoff origin of the right brachiocephalic artery – “Entry from the back door”. J Indian coll cardiol [serial online] 2019 [cited 2019 May 19];9:47-9. Available from: http://www.joicc.org/text.asp?2019/9/1/47/257956




  Introduction Top


The inability to cross guidewire is one of the main reasons for failure in percutaneous stenting of the ostioproximal stenosis of the right brachiocephalic artery. The difficulty is usually a tortuous aortic arch or an unfavorable supra-aortic takeoff. Several techniques are described to overcome this problem. In this case report, we describe a combined technique that we have found to be quite useful in patients who have an unfavorable arch anatomy and eccentric lesion, which was difficult to cross. We have used a specific case as an example to illustrate this technique.

Learning objectives

Right brachiocephalic artery stenoses are difficult to access due to the eccentricity of the lesion and unusual takeoff from the arch of the aorta. Combined transfemoral and transbrachial approach can be an easy way to tackle these difficulties.


  Case Report Top


A 55-year-old male, heavy smoker and hypertensive, presented with weakness of the left upper and lower limb for 2 days with aphasia. The patient had normal vital signs. On admission, the patient was subjected to the computed tomography of the brain, which showed right thalamic infarct. Hence, the patient was started with aspirin 150 mg, clopidogrel 75 mg, and enoxaparin 60 mg.

The patient recovered of his symptoms next day, and computed angiography of the supra-aortic vessels revealed critical stenosis of the proximal segment of the right brachiocephalic artery and normal left carotid and subclavian arteries. After consultation with neurophysician and radiologist, percutaneous transluminal angioplasty was planned after 2 weeks.

The right femoral artery was cannulated using 6-Fr sheath and 6-Fr right coronary guide catheter to engage the right innominate artery. There was difficulty in crossing the stenosis, as it was eccentric lesion [Figure 1]a. After some efforts, whisper extra support guidewire could cross the lesion and was predilated using 5.0 mm × 15 mm balloon [Figure 1]b. We tried exchanging with 8-Fr sheath, but it could not negotiate up to the right brachiocephalic artery. Hence, the right brachial artery was cannulated, and 0.035 wire was crossed easily retrograde into the descending aorta [Figure 1]c. Through transfemoral approach, the right coronary diagnostic catheter was used for the visualization of stent across the lesion [Figure 1]d. Furthermore, radio-opaque marker (scalpel handle) was placed externally across the midpoint of the lesion, and catheterization laboratory table was fixed. The 10 mm × 37 mm “Scuba” balloon-expandable stent was deployed across the ostioproximal segment of the right innominate artery [Figure 1]e. Check angiography revealed good expansion of stent and normal flow across the carotid–vertebral and subclavian arteries [Figure 1]f. The patient had no neurological deficit and was discharged on the 2nd day postprocedure with advice of optimal medical management in the form of dual-antiplatelet agents (aspirin and clopidogrel), angiotensin-converting-enzyme inhibitor, beta-blocker, and high-intensity statin.
Figure 1: Stepwise demonstration of peripheral percutaneous angioplasty of the right brachiocephalic artery stenosis which was eccentric (solid arrow, a) and unfavorable supra-aortic takeoff (dotted curvilinear line, c) from the aortic arch. Initially, a transfemoral approach was used and could cross with coronary 0.014' whisper extra support guidewire using 6-Fr right coronary guide catheter (b). The lesion was dilated using 5.0 mm × 15 mm balloon (b). For the deployment of the stent, we could not negotiate larger 8-Fr guide catheter/delivery sheath (not shown). The transbrachial approach was used to deploy 10 mm × 37 mm balloon-expandable stent across the lesion (dashed arrow, d) under angiographic guidance from the transfemoral right coronary diagnostic catheter (e) and externally placed scalpel handle across the lesion as a radiopaque marker (c-f). Final check angiography showed no residual stenosis with a brisk flow (f)

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  Discussion Top


Earlier in 1950–1970, there are several reports and case series of the management of high-grade stenosis of the aortic arch vessels with surgical repairs with high morbidity and mortality rates. Later in the 1970s, percutaneous modalities of treatment emerged to manage peripheral vessels like renal, carotids, mesenteric vessels, etc.[1] Since then, percutaneous angioplasty with stent is rapidly becoming a common method of treatment for right brachiocephalic stenosis. As interventionists have gained wide experience with this procedure, several technical modifications of the technique for gaining access to the involved innominate arteries have been described.

In India, the most common etiology is atherosclerosis and Takayasu's aortoarteritis. Symptoms range from ischemia of the right upper extremity to the anterior or posterior cerebral circulation or a combination of upper extremity and diffuse neurological symptoms.[2]

In three case series of percutaneous angioplasty of right innominate artery stenosis, the procedural success rate of varied from 96.4% to 88%.[3],[4],[5] In all the case series, the indications for endovascular treatment were as follows: neurologic symptoms, upper limb claudication or digital embolization, and asymptomatic patients with multivessel disease with or without subclavian steal syndrome.[3]

In our case, the technical challenge was primarily crossing the lesion and maintaining support of the sheath secondary to anatomical difficulties imposed by a very high-grade stenosis. In case series by Paukovits et al., 5.6% of innominate artery lesions could not be crossed through transfemoral approach. Hence, they performed right brachial artery cannulation to access sight innominate stenosis and to deploy stent as in our case.[3] Peterson et al. in their single-center experience of aortic arch vessel stenting performed eight cases of innominate artery stenting. They have used combined approaches for the angioplasty of innominate artery stenting. In one of their cases, they did retrograde stenting through brachial artery puncture without using neuroprotection device due to technical difficulty as in our case.[1]


  Conclusion Top


In our case, there was an eccentric lesion, which was difficult to cross; hence, we adapted a combined approach for the intervention of right brachiocephalic artery stenosis. The success rate of right innominate artery angioplasty has increased due to the combined approach, availability of new, lower profile balloons and stents, and experience of interventionists. Percutaneous angioplasty of the right innominate artery using stent improves long-term outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peterson BG, Resnick SA, Morasch MD, Hassoun HT, Eskandari MK. Aortic arch vessel stenting: A single-center experience using cerebral protection. Arch Surg 2006;141:560-3.  Back to cited text no. 1
    
2.
Ryer EJ, Oderich GS. Two-wire (0.014 & 0.018-inch) technique to facilitate innominate artery stenting under embolic protection. J Endovasc Ther 2010;17:652-6.  Back to cited text no. 2
    
3.
Paukovits TM, Lukács L, Bérczi V, Hirschberg K, Nemes B, Hüttl K, et al. Percutaneous endovascular treatment of innominate artery lesions: A single-centre experience on 77 lesions. Eur J Vasc Endovasc Surg 2010;40:35-43.  Back to cited text no. 3
    
4.
van Hattum ES, de Vries JP, Lalezari F, van den Berg JC, Moll FL. Angioplasty with or without stent placement in the brachiocephalic artery: Feasible and durable? A retrospective cohort study. J Vasc Interv Radiol 2007;18:1088-93.  Back to cited text no. 4
    
5.
Hüttl K, Nemes B, Simonffy A, Entz L, Bérczi V. Angioplasty of the innominate artery in 89 patients: Experience over 19 years. Cardiovasc Intervent Radiol 2002;25:109-14.  Back to cited text no. 5
    


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