Complete Revascularization of Total Obstruction of Both
Subclavian Arteries and Descending Abdominal Aorta by
Combined Surgery

The vast majority of symptomatic lesions of the aortic arch involve the subclavian artery.1 Since Bachman and Kim first reported a case of successful subclavian artery angioplasty in 1980,2 percutaneous transluminal angioplasty (PTA) has become a well established treatment modality for patients with atherosclerotic stenosis of subclavian artery.3 Chronic infrarenal aortic occlusion has a broad spectrum of ischemic manifestations, and aortofemoral bypass graft surgery has been considered as a gold standard in the treatment of aortoiliac artery occlusive disease. Total occlusion of both subclavian arteries and the descending abdominal aorta in one patient is rare and there are few reports mentioning the combined application of end-to-side aorta-to-bifemoral graft surgery and PTA. We report a patient with total occlusion of infrarenal descending abdominal aorta and both subclavian arteries, which was successfully treated with end-to-side aorta-to-bifemoral graft surgery and PTA, respectively. Case Report. A 48-year-old man was transferred to our hospital for chest pain, intermittent claudication and right upper extremity weakness for a month. The patient had a history of acute myocardial infarction one month prior. However, coronary angiography could not be performed because both subclavian arteries and the abdominal aorta were totally occluded. He also had diabetes mellitus for over one year and a 45-pack/year smoking history. The pulsation of both femoral arteries was absent. His leukocyte count was 11,020/mm3 (eosinophil 14.4%), C-reactive protein 0.922 mg/dl (normal range: 0–0.8) and ESR (wintrobe) 44 mg/dl (normal range: 0–10). ANA, anti-dsDNA, ANCA (IFA), lupus anticoagulant, anti-cardiolipin Ab IgG and anti-cardiolipin Ab IgM were negative. On ECG, Q-wave was observed in lead II, III, aVF, V5, and V6. Reduced left ventricular systolic function (ejection fraction = 42%) and the akinesia of the inferoseptum and inferior wall were observed in echocardiography. Magnetic resonance angiography (MRA) showed total occlusion of the descending aorta below the renal artery level and both subclavian arteries (Figure 1). Despite of medical treatment with enteric-coated aspirin, cilostazole and prostaglandin E1 for one year, the pain and weakness of both legs and arms increased. Thus, end-to-side aorta-to-bifemoral graft surgery with Hemashield 18¥9 mm (Meadox Medicals, Oakland, New Jersey) was performed, and the pulsations of both femoral arteries returned after bypass surgery. Three months after bypass surgery, coronary angiography was performed through the left femoral artery below the level of the graft. After puncturing the left femoral artery through the anastomosis site, where the femoral artery was connected to the aorta end-to-side, a guidewire and catheter were passed to the descending aorta. It revealed discrete eccentric 60% luminal narrowing of the mid-right coronary artery. At the same time, it also revealed total obstruction of the right and left subclavian arteries with a lesion length of 70 mm and 55 mm, respectively. The distal portions of both subclavian arteries were visualized by retrograde collateral flow from each vertebral artery (Figures 2A and 3A). Since the brachial artery could not be palpated due to total occlusion of right subclavian artery, we tried to visualize the brachial artery first by using collateral flow from the vertebral artery through the insertion of an 8 Fr shuttle‚ SL Flexon‚ sheath (Cook, Bloomington, Ind.) to the right inominated artery and the injection of contrast dye. The brachial artery was punctured under the guidance of retrograde collateral flow, and a Multipurpose 5 Fr catheter (Cook, Bloomington, Ind.) was inserted via a brachial sheath. A straight 0.035-inch, 260 cm long hydrophilic wire (Terumo, Tokyo, Japan) was advanced through the multipurpose catheter and passed through the occluded right subclavian artery. The passed guidewire was caught by a Snare (Microvena, White Bear Lake, Minn.), which was introduced through the sheath previously placed at the right inominated artery. The snare pulled out the guidewire via the femoral sheath, and a multipurpose 5 Fr catheter was inserted over the guidewire from the femoral puncture site. After passing the catheter through the lesion, the guidewire was changed to a curved 0.035-inch, 260 cm TEF-coated heavy duty catheter exchange (Cook, Bloomington, Ind.) for UDT (Ultra-thin diamond) peripheral balloon (Boston Scientific, Watertown, Mass.), 6 mm in diameter and 40 mm in length. Under systemic anticoagulation with heparin, 5,000 U (ACT > 350 seconds), the balloon was inflated twice at 6 atmospheres for 20 seconds. Follow-up angiography revealed 30% residual stenosis. A SMART peripheral stent (Shape memory alloy recoverable technology, Cordis, Miami, Florida), which was 6 mm in diameter and 100 mm in length, was deployed. Follow-up angiography revealed less than 10% residual stenosis (Figure 2B). One month after PTA of the right subclavian artery, PTA of the left subclavian artery was performed with the same method via the left femoral and left brachial arteries. Using a UDT peripheral balloon 6 mm in diameter and 40 mm in length under systemic anticoagulation with heparin (ACT > 350 seconds), the balloon was inflated to 8 atmospheres for 29 seconds. Follow-up angiography revealed 50% residual stenosis. A SMART peripheral stent (10 mm in diameter and 80 mm in length) was deployed, and follow-up angiography revealed 30% residual stenosis. Therefore, adjunctive balloon dilatation at 14 atmospheres for 28 seconds with a UDT peripheral balloon (8 mm in diameter and 40 mm in length) was supplemented. Follow-up angiography revealed less than 10% residual stenosis (Figure 3B). At 6 months follow-up, angiography performed due to progressive weakness of the patient’s right arm revealed 70% restenosis of the stent at the right subclavian artery (Figure 4A), but a patent left subclavian artery (Figure 5). The patient underwent PTA of the right subclavian artery, again. The symptoms disappeared after the procedure (Figure 4B). Discussion. Chronic infrarenal atherosclerotic aortic occlusion is a rare entity with an occurrence of 0.15% in 31,216 autopsies.4 Since Moore et al. and Perdue et al. advocated aortofemoral bypass graft surgery, the aortofemoral procedure has been considered a gold standard in the treatment of aortoiliac occlusive disease because of excellent long-term patency rates.5,6 Primary patency rates of 76.6% to 95% at 5 years and 75% at 10 years have been reported.7,8 As described by Ligish et al, the survival rates of all patients who had infrarenal aortic obstruction was 67% at 5 years.9 Obstructive lesions of the innominate or subclavian artery can cause not only claudication of the arm, but also symptoms of subclavian steal syndrome and coronary-subclavian steal syndrome. The vast majority of symptomatic lesions of the aortic arch involve the subclavian artery and the left subclavian artery is affected 3 to 4 times more frequently than right side.10 In the chronic stage of symptomatic subclavian artery occlusion, bypass graft surgery has been regarded as a standard method that had a complication rate of up to 23% and a mortality rate of 4.8–8%.1,11 Dotter and Judkins proposed the application of catheter-based treatment of arterial occlusion nearly 30 years ago.9 However, according to a report by Faina et al, which compared the results of 21 patients who had undergone PTA and surgery for subclavian artery occlusion, actual patency of PTA was 54%, while the surgical patency rate was 87%. This unfavorable result from PTA was due to late stenosis.12 Recently, Rodriguez-Lopez et al reported that stenting for subclavian artery stenosis appeared to be safe and feasible with good short- and mid-term patency, relieving initial disappointment by reports of PTA alone.13 In total occlusion of the subclavian artery, Martinez et al. reported a 94% procedural success rate and no post-procedural neurological complications or death. Follow-up over a mean duration of 19.4 months revealed 1 case of asymptomatic restenosis after 5 months in a patient previously treated with 3 stents.14 We diagnosed the total occlusion of a bilateral subclavian artery and a descending abdominal aorta by MRA, but cathetaerization was not possible. Thus, aortofemoral bypass graft surgery was performed in advance, and then PTA was performed via the femoral and brachial approach. Since the occluded lesion was chronic and long, we tried to avoid dissection by approaching the true lumen simultaneously through the femoral and brachial arteries. We did not expect distal embolization to the vertebral artery territory with PTA because both vertebral arteries were visualized by retrograde collateral flow. However, we did expect late occlusion of the stent at the right subclavian artery since the patient was right-handed. In conclusion, we report a case of totally occluded subclavian arteries and the descending abdominal aorta, revascularized by PTA after aortofemoral bypass. However, further follow-up would be needed to establish the usefulness of this approach.

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