ENDOVASCULAR AND SURGICAL TECHNIQUES Successful …Embolism of upper limb vessels is the commonest...
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Eur J Vasc Endovasc Surg 13, 217-218 (1997) ENDOVASCULARAND SURGICAL TECHNIQUES Successful Stenting of Subclavian Artery Thrombus with Intra-arterial Thrombolysis B. J. Ammori .1, M. Madan 1, P. M. Chennells 2, R. C. Fowler 2 and S. Homer-Vanniasinkam 1 Departments of 1Vascular Surger*t and 2Radiology, Leeds General Infirmary, Great George Street, Leeds, U.K. Introduction Intravascular stents are acquiring an expanding role in the treatment of arterial and venous disorders. ~-3 Stents have been successfully used to treat common iliac embolus complicating angioplasty, 4 and sub- clavian artery intimal tear following blunt trauma. 5 We describe the successful treatment of a subclavian artery thrombus with distal embolisation resulting in acute limb aschaemia by stent application and percu- taneous thrombolysis. arteries and 10 mg of tissue plasminogen activator was infused over 12 h, with satisfactory resolution of the thrombus. A good radial pulse was established and the subclavian bruit disappeared. She was anti- coagulated with heparin and subsequently warfarin. Thorough investigations including transoesopha- geal echocardiogram and a thrombotic screen have failed to demonstrate any abnormality. At 3 months follow-up she remained asymptomatic with no arm claudication. The distal phallanx of the left little finger had become gangrenous and under- gone autoamputation. Left arm brachial pressure was Case Report A 32-year-old female presented with an acutely ischaemic left hand. She gave a history of trauma to her left shoulder 2 weeks earlier, but was otherwise well. On examination she had a critically ischaemic left hand with a pre-gangrenous tip of little finger, an absent radial pulse, a weak brachial pulse, and an audible bruit over the left subclavian artery. An urgent arteriogram demonstrated thrombus at the origin of the left subclavian artery (Fig. 1), with no obvious underlying cause. Both radial and ulnar arteries were occluded proximally. The aortic arch appeared normal on both arteriography and CT- scanning. A Palmaz stent was successfully deployed across the filling defect in the left subclavian artery through a right groin approach, establishing full luminal patency (Fig. 2). A 3 Fr catheter was then advanced through the stent into both radial and ulnar *Please address all correspondenceto: Mr B. J. Ammori,Department of Vascular Surger3~ Leeds General Infirmary, Leeds LS1 3EX, U.K. Fig. 1. Arteriogram:Thrombus at the proximal left subclavianartery with marked luminal narrowing. 10785884/97/020217 + 02 $12.00/0 © 1997 W. B. Saunders Company Ltd.
Transcript of ENDOVASCULAR AND SURGICAL TECHNIQUES Successful …Embolism of upper limb vessels is the commonest...
Eur J Vasc Endovasc Surg 13, 217-218 (1997)
ENDOVASCULAR AND SURGICAL TECHNIQUES
Successful Stenting of Subclavian Artery Thrombus with Intra-arterial Thrombolysis
B. J. Ammori .1, M. Madan 1, P. M. Chennells 2, R. C. Fowler 2 and S. Homer-Vanniasinkam 1
Departments of 1Vascular Surger*t and 2Radiology, Leeds General Infirmary, Great George Street, Leeds, U.K.
Introduction
Intravascular stents are acquiring an expanding role in the treatment of arterial and venous disorders. ~-3 Stents have been successfully used to treat common iliac embolus complicating angioplasty, 4 and sub- clavian artery intimal tear following blunt trauma. 5 We describe the successful treatment of a subclavian artery thrombus with distal embolisation resulting in acute limb aschaemia by stent application and percu- taneous thrombolysis.
arteries and 10 mg of tissue plasminogen activator was infused over 12 h, with satisfactory resolution of the thrombus. A good radial pulse was established and the subclavian bruit disappeared. She was anti- coagulated with heparin and subsequently warfarin.
Thorough investigations including transoesopha- geal echocardiogram and a thrombotic screen have failed to demonstrate any abnormality.
At 3 months follow-up she remained asymptomatic with no arm claudication. The distal phallanx of the left little finger had become gangrenous and under- gone autoamputation. Left arm brachial pressure was
Case Report
A 32-year-old female presented with an acutely ischaemic left hand. She gave a history of t rauma to her left shoulder 2 weeks earlier, but was otherwise well. On examination she had a critically ischaemic left hand with a pre-gangrenous tip of little finger, an absent radial pulse, a weak brachial pulse, and an audible bruit over the left subclavian artery.
An urgent arteriogram demonstrated thrombus at the origin of the left subclavian artery (Fig. 1), with no obvious under lying cause. Both radial and ulnar arteries were occluded proximally. The aortic arch appeared normal on both arteriography and CT- scanning. A Palmaz stent was successfully deployed across the filling defect in the left subclavian artery through a right groin approach, establishing full luminal patency (Fig. 2). A 3 Fr catheter was then advanced through the stent into both radial and ulnar
*Please address all correspondence to: Mr B. J. Ammori, Department of Vascular Surger3~ Leeds General Infirmary, Leeds LS1 3EX, U.K.
Fig. 1. Arteriogram: Thrombus at the proximal left subclavian artery with marked luminal narrowing.
10785884/97/020217 + 02 $12.00/0 © 1997 W. B. Saunders Company Ltd.
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110/70 mmHg, compared with a right arm pressure of 120/80 mmHg. A duplex scan of her subclavian, vertebral and carotid arteries demonstrated normal waveforms and flow velocities. As the patient remained asymptomatic, follow-up angiography was not performed.
Discussion
Embolism of upper limb vessels is the commonest cause of acute arm or hand ischaemia. 6 In the majority of cases emboli originate in the heart 7 and lodge at or just below the brachial artery. An embolus or throm- bus lodged in the proximal subclavian artery is unusual. 6 A history of trauma in this patient with absence of any cardiac or aortic pathology suggests an intimal tear at the proximal part of the subclavian artery with subsequent thrombus formation and distal embolisation.
Transbrachial embolectomy remains the treatment of choice for the majority of acute upper limb embolic ischaemia. However, the location of a thrombus at the origin of the subclavian artery poses a difficult management problem. Catheter embolectomy under this circumstance carries the potential risk of dis- lodging the thrombus either proximally into the aorta or distally into the vertebral artery with subsequent visceral, lower extremity or cerebral catastrophic
Fig. 2. Arteriogram: Palmaz stent placed across the thrombus restoring full luminal patency.
ischaemic complications. For the same reasons percu- taneous aspiration thromboembolectomy was not attempted. Furthermore, it is well recognised that balloon catheter embolectomy can result in intimal damage, particularly of small vessels, with subsequent thrombosis. 8 A possible trauma-related intimal tear in this case made us wary of the retrograde transbrachial approach.
A percutaneous endovascular approach was there- fore our option of choice. A covered stent would have been preferable in such a circumstance, but as it was not available a Palmaz stent was used. This was deployed antegradely across the thrombus, apposing it against the arterial wall and establishing full luminal patency. The stent also addressed the possibil- ity of a proximal subclavian intimal tear.
Success of proximal thrombus stenting combined with distal percutaneous thrombolysis was clearly demonstrated in this case by a sustained clinical recover~ and the demonstration of normal blood flow into the subclavian artery on both angiography and colour-flow duplex scanning.
We conclude that this is an effective therapeutic option in the management of selected cases of acute thromboembolic limb ischaemia. It carries, however, the risk of dislodging a proximal thrombus with further distal embolisation when surgery may be required.
References
1 ROSENBLUM JD~ LEEF JA, KOSTELIC JK, BOYLE CM. Angioplasty and intravascular stents in peripheral vascular disease. Surg Clin North Amer 1995; 75: 621-632.
2 AHN SS, ETON D, MOORE WS. Endovascular surgery for periph- eral arterial occlusive disease. A critical review. Ann Surg 1992; 216: 3-16.
3 ZOLLIKOFER CL, 8CHOCH E, STUCKMANN G e t al. Percutaneous transluminal treatment of stenoses in the venous system using vascular endoprostheses (stents). [Review] Journal Suisse de Medecine 1994; 124: 995-1009.
4 ACKROYD R, HARRIS N, GAINES PA. Case report: Percutaneous stenting: A novel way of treating an embolus. Clin Radiol 1995; 50: 346-348.
5 JACKSON SA, TisI PV, ODURNY A, SHEARMAN CP. Endovascular stenting in the management of blunt subclavian artery trauma. J Int Radiol 1996; 11: 25-27.
6 RIcorra JJ, SCUDDER PA, McANDREW JA et al. Management of acute ischemia of the upper extremity. Am J Surg 1983; 145: 661.
7 BREWSTER DC, CHIN AK, HERMANN GD, FOGERTY TJ. Arterial thromboembolism. In: RUTHERFORD RB, ed. Vascular surgery. Philadelphia: W.B. Saunders, 1995: 647-668.
8 JORGENESEN RA, DOLBRIN PB. Balloon embolectomy catheters in small arteries, IV. Correlation of sheer forces with histological injury. Surgery 1983; 93: 798.
Accepted 11 September 1996
Eur J Vasc Endovasc Surg Vol 13, February 1997
