Subclavian Artery Stenosis

Clinical History

69 yo smoker presents with dusky painful fingertips on the right hand and diminished radial and brachial pulses.  Doppler revealed Monophasic waveforms throughout the right arm with elevated velocities in the right brachial artery.  Angiography was performed.


Angiogaphy of the Aorta

 


Image 1.1

Angiogram of the Aorta reveals a high grade densely calcified stenosis of the proximal right subclavian artery, and reversed flow in the right vertebral artery.








Intervention


Image 2.1

Placement of a balloon expandable stent accross the stenosis. Note the Spider-Wire (Boston Scientific) embolic protection device in the proximal common carotid artery.



Image 2.2

Partial deployment of the stent.



Image 2.3

Fully deployed stent. Note the persistent stenosis due to the bulky and dense nature of the excluded calcification.



Image 2.4

Video showing controlled but rapid deployment of the stent to nominal balloon pressure.



Image 2.5

Completion angiogram demonstrates wide patency of the stent with brisk and symmetrical arterial flow.




Angiography of the right arm


Image 3.1

Angiogram reveals a long segment of FMD (fibromuscular dysplasia) involving the brachial artery. Given the patient's recent embolic episode and tenuous peripheral circulation, we elected to treat.



Image 3.2

Angioplasty using a 5mm x 100mm balloon was performed to break apart the webs.



Image 3.3

Post-Treatment angiogram reveals persistent beading with an appearance similar to the pre-treatment angiogram. This is normal for FMD. The flow-limiting webs have been disrupted which should produce a positive clinical result.






Case Discussion

Would you have used embolic protection?  If so, what device and why?  Is there anything else you would have done differently?  Please feel free to leave comments and questions below.

 


Case Credits

Images and content graciously provided by:

Jason Himmel, MD


References

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