Subclavian Stent Recoil: Endovascular Management Using a Manually Crimped High Radial Strength Bare Metal Stent

Abstract

Subclavian steal phenomenon has been described in patients with reversal of flow in the vertebral arteries to supply an underperfused upper extremity due to severe subclavian artery stenosis. The syndrome is easily corrected by stenting of the subclavian artery and restoration of antegrade flow into the subclavian and vertebral arteries. We present a unique case of right subclavian artery stenosis resulting in a subclavian steal syndrome, managed with percutaneous stenting but complicated by stent recoil requiring the use of a manually crimped stent with increased radial strength to support the patency of the vessel.

VASCULAR DISEASE MANAGEMENT 2013:10(2):E23-E25

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Case Report

A 61-year-old white female with known history of coronary artery bypass grafting 12 years prior was referred for evaluation of right upper extremity claudication and dizziness with exertion of the right arm. At the time of presentation, she was found to have unequal blood pressures bilaterally and noted to have right carotid and subclavian bruits. Subclavian and carotid duplex ultrasound confirmed right brachiocephalic artery occlusion with low internal carotid artery velocities (peak systolic velocity 39 cm/sec; unable to measure end diastolic velocity) and retrograde flow in the right vertebral artery.

Fluoroscopy of the aortic arch revealed a heavily calcified porcelain arch. Right brachiocephalic artery angiogram revealed heavily calcified 100% ostial occlusion (Figure 1). At this point, the decision was made to intervene on the right brachiocephalic artery occlusion in the setting of symptomatic disease. 

Access was secured in the right brachial artery and right common femoral artery with 6 Fr and 7 Fr sheaths respectively. A V-18 wire (Boston Scientific) was advanced with support of a Sterling 4 x 20 mm balloon (Boston Scientific) to cross the right brachiocephalic artery occlusion into the aorta. Selective angiogram through the balloon into the aorta confirmed an intraluminal position in the aortic arch. A 35-mm gooseneck snare (eV3) was advanced from the right femoral artery through a 7 Fr Pinnacle Destination Sheath (Terumo) to capture the V-18 wire and to externalize it through the right femoral artery. After serial dilatations, an ICAST 7 x 22 mm covered stent (Atrium) was deployed at the ostium of the right brachiocephalic artery at 14 atm. Multiple angulated views confirmed ostial coverage of the vessel with the stent. However, the stent was noted to recoil from the surrounding calcifications despite multiple attempts at aggressive postdilatation with serially larger balloons (Figure 2). A manually crimped Palmaz stent (Cordis) was then deployed within the previous stent to provide greater radial strength and expansion of the stent with minimal recoil (Figure 3). Final angiogram confirmed brisk flow through the stented segment with no residual gradient (Figures 4 and 5). Follow-up carotid ultrasound showed peak systolic and diastolic velocities in the right internal carotid artery to be 149 and 36 respectively with antegrade flow in the vertebral artery. 

Discussion

A physiologic steal occurs when there is a pressure gradient between the donor and recipient arteries.¹ Subclavian steal syndrome (SSS) has been described in patients with hemodynamically significant subclavian artery stenosis proximal to the origin of the vertebral artery and reversal of flow through the vertebral artery to perfuse the upper extremity during exercise.² The incidence of SSS is reported to be around 6.5% in patients undergoing assessment of carotid arteries.³

Treatment of SSS is primarily percutaneous with angioplasty and stenting, and rarely surgical with carotid-subclavian bypass or direct endarterectomy.⁴ The use of covered stents to treat proximal subclavian artery stenosis has been evaluated previously, offering potential advantages of reduced intimal hyperplasia and improved patency rates.⁵ However, the prevalence of stent recoil is unknown: small studies utilizing intravascular ultrasound imaging on follow-up evaluation, have demonstrated a positive correlation between stent overexpansion and recoil.⁶ More frequently, stent recoil occurs due to heavy calcification and undilatable lesions.⁷ The mechanical properties of bare metal stents are highly variable based on stent composition and design, with the Palmaz stent demonstrated to have relatively high radial strength.⁸

Conclusion

We present herein a unique case of SSS, managed with percutaneous stenting, but complicated by stent recoil due to extensive calcification, requiring the use of a manually crimped stent with increased radial strength to support the patency of the vessel.

References

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