Will the Transradial Approach Become the Preferred Approach in Subclavian Artery Stenting?

Subclavian artery stenting is well established in the therapy of subclavian artery stenosis resulting in “subclavian steal,” arm claudication, myocardial ischemia in patients with prior or intended coronary artery bypass utilizing the internal mammary artery, and in patients with leg ischemia who have undergone axillofemoral bypass. ^1–9 The single-center experience published in the current issue of the Journal by Yu and colleagues10 describes their experience utilizing the transradial approach in the treatment of symptomatic subclavian artery lesions. The transradial approach is increasingly being utilized in diagnostic and interventional procedures throughout the vascular system, as bleeding complications are nonexistent and patients can ambulate immediately. ^11–20 This approach can be utilized in fully anticoagulated patients without reversal of anticoagulation or antiplatelet drugs. It can be utilized safely where there is extensive lower-extremity atherosclerotic disease or in cases where there are abdominal aortic aneurysms with risk of peripheral embolization. As compared to the femoral approach in subclavian and upper-extremity intervention, the radial approach provides better support and avoids manipulation of catheters in the aortic arch and the potential danger of catheter injury of the origins of the great vessels that is inherent with a transfemoral approach. The brachial approach is limited in subclavian artery stenoses by potential bleeding complications, weak pulse and vessel mobility, making access difficult. Limitations of the radial approach include: 1) there must be a patent radial artery; 2) there must be a patent ulnar artery with evidence of adequate blood supply to the hand evaluated by the Allen’s test (Figure 1), as there is up to a 2% risk of radial artery occlusion following transradial access; 3) visualization of the origin of the great vessels at stent implantation may be difficult (injecting against blood flow typically via small sheaths; and 4) occasionally, vascular spasm may occur. If visualization is an issue, a 4 Fr femoral catheter can be placed in the aortic arch to allow appropriate visualization for optimal stent deployment. Whereas many occlusions are more easily crossed in retrograde fashion via the radial artery, occasionally when retrograde crossing is unsuccessful, then crossing can be performed antegrade via the femoral approach utilizing catheters or wires placed via the radial approach as markers to aid guidewire crossing. As with any approach, operator training and experience is paramount in utilizing the transradial approach in any diagnostic or interventional procedure. With appropriate training the transradial approach can clearly decrease access-site bleeding complications and may increase the rate of successful crossing of subclavian occlusions by providing better support thereby enhancing crossing success or by marking the subclavian artery for facilitating crossing via femoral approach. To avoid ischemic complications of this approach it is mandatory that assessment of collateral flow via a patent ulnar artery be evaluated prior to the procedure.

References

1. Schillinger M, Haumer M, Schillinger S, et al. Risk stratification for subclavian artery angioplasty: Is there an increased rate of restenosis after stent implantation? J Endovasc Ther 2001;8:550–557. 2. Hebrang A, Maskovic J, Tomac B. Percutaneous transluminal angioplasty of the subclavian arteries: Long-term results in 52 patients. Am J Roentgenol 1991;156:1091–1094. 3. Phipp LH, Scott DJ, Kessel D, Robertson I. Subclavian stents and stent-grafts: Cause for concern? J Endovasc Surg 1999;6:223–226. 4. Kim JY, Lee SH, Choe HM, et al. The feasibility of percutaneous transradial coronary intervention for chronic total occlusion. Yonsei Med J 2006;47:680–687. 5. Van Noord BA, Lin AH, Cavendish JJ. Rates of symptom reoccurrence after endovascular therapy in subclavian artery stenosis and prevalence of subclavian artery stenosis prior to coronary artery bypass grafting. Vasc Health Risk Manag 2007;3:759–762. 6. Henry M, Amor M, Henry I, et al. Percutaneous transluminal angioplasty of the subclavian arteries. J Endovasc Surg 1999;6:33–41 7. Celkan MA, Daglar B, Kazaz H, Dinckal H. Symptomatic coronary-subclavian steal syndrome due to total occlusion of proximal left subclavian artery. Interact Cardiovasc Thorac Surg 2003;2:534–536. 8. Pollard H, Rigby S, Moritz G, Lau C. Subclavian steal syndrome: A Review. Australas Chiropr Osteopathy 1998;7:20–28. 9. Gimelli G, Tefera G, Turnipseed WD. Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting — A case report. Vasc Endovascular Surg 2006;40:235–238. 10. Yu J, Korabathina R, Coppola J, Staniloae C. Transradial approach to subclavian artery stenting. J Invasive Cardiol 2010;22:204–206. 11. Stone GW, Grines CL, Cox DA, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 2002;346:957–966. 12. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1999;341:1949–1956. 13. Nordmann AJ, Hengstler P, Harr T, et al. Clinical outcomes of primary stenting versus balloon angioplasty in patients with myocardial infarction: A meta-analysis of randomized controlled trials. Am J Med 2004;116:253–262. 14. Lemos PA, Saia F, Hofma SH, et al. Short- and long-term clinical benefit of sirolimus-eluting stents compared to conventional bare stents for patients with acute myocardial infarction. J Am Coll Cardiol 2004;43:704–708. 15. Baumgart D, Klauss V, Baer F, et al. One-year results of the SCORPIUS study: A German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients. J Am Coll Cardiol 2007;50:1627–1623. 16. Menichelli M, Parma A, Pucci E, et al. Randomized trial of Sirolimus-Eluting Stent Versus Bare-Metal Stent in Acute Myocardial Infarction (SESAMI). J Am Coll Cardiol 2007;49:1924–1930. 17. Menozzi A SE, Ortolani P, Repetto A, et al. Sirolimus-eluting stents reduce the incidence of late adverse events in patients with small coronary arteries. Results from the two-year follow-up of the SES-SMART trial. Eur Heart J 2007;28:327. 18. Palmieri C, Ravani M, Trianni G, et al. Drug-eluting stent versus bare-metal stent in acute ST-segment elevation myocardial infarction. A single-center experience with a long-term follow-up. J Invasive Cardiol 2010;22:151–158. 19. Kaul S, Diamond GA. Trial and error. How to avoid commonly encountered limitations of published clinical trials. J Am Coll Cardiol 2010;55:415–427. 20. Spaulding C, Henry P, Teiger E, et al. TYPHOON Investigators. Sirolimus-eluting versus uncoated stents in acute myocardial infarction. N Engl J Med 2006;355:1093–1104.

_________________________________________________________________________ From the Cardiovascular Institute of the South, Houma, Louisiana. The author reports no conflicts of interest regarding the content herein. Address for correspondence: Craig Walker, MD, Vascular Laboratory, Cardiovascular Institute of the South, 225 Dunn Street, Houma, LA 70360. E-mail: craig.walker@cardio.com