Endovascular Treatment of Subclavian Artery Occlusion by Surgical Exposure of the Proximal Brachial Artery at the Side of an Arteriovenous Fistula

Abstract

A 76-year-old man undergoing hemodialysis complained of pain and discoloration of his right finger. The hemodialysis arteriovenous fistula was in the right upper extremity. Ultrasonography showed right subclavian artery occlusion. The lesion could not be approached from the lower extremity and olecranon artery. Thus, we performed the procedure after exposing the proximal brachial artery. We were able to recanalize the subclavian artery and restore blood flow to the right upper extremity. When the lesion is on the side of the arteriovenous fistula and approaching from the lower extremity is difficult, exposure of the proximal brachial artery can be considered.

Introduction

Decreased blood flow in the peripheral arteriovenous fistula and complaints of upper extremity pain are among the most common complications in patients undergoing hemodialysis. One cause is occlusion of the subclavian artery on the side of the arteriovenous fistula. In recent years, endovascular therapy has been considered the first-line treatment for symptomatic subclavian artery occlusion because it is less invasive than surgery, is associated with fewer complications, and has a higher success rate (1). If the lesion is on the side of the shunt, a lower extremity approach to maintain the hemodialysis arteriovenous fistula is considered. However, in the present case, approaching from the lower extremities was difficult. Therefore, to restore blood flow in the subclavian artery while maintaining the arteriovenous fistula, we collaborated with a vascular surgeon to surgically expose the right brachial artery as an access point. We report a case of subclavian artery occlusion with upper extremity blood flow disturbance that was difficult to approach for endovascular therapy.

Case Report

A 76-year-old man presented with complaints of pain and discoloration of the right fifth finger for two days. He had previously been diagnosed with peripheral artery disease and was taking antiplatelet medication. The patient was referred to our hospital because blood flow in the ulnar artery was barely visible on ultrasonography. His relevant medical history included smoking, hypertension, diabetes mellitus, and end-stage renal failure secondary to diabetic nephropathy. He was undergoing hemodialysis three times per week. The arteriovenous fistula was located in the right upper extremity. The ankle-brachial pressure index was not measurable, and ultrasonography of the upper extremity vasculature showed occlusion of the right subclavian artery pulse and severe stenosis of the right radial and ulnar arteries (Fig. 1A, B). We hypothesized that this was the cause and that catheterization of these arteries to relieve the occlusion would bring about relief of his symptoms. We performed a preoperative evaluation using contrast-enhanced computed tomography (Fig. 1C-F). We used a left femoral artery approach due to occlusion in the right common iliac artery (Fig. 2A). However, a large angle of bifurcation from the brachiocephalic artery to the subclavian artery weakened the backup force of the guiding catheter; thus, we could not pass the guidewire across the lesion. The presence of plaque in the common carotid artery also made the procedure difficult because of the high risk of stroke. Therefore, the femoral artery approach was not considered. Subsequently, the right radial and ulnar artery stenoses were first punctured from the arteriovenous fistula as usual, and balloon dilatation was performed. The blood flow in both arteries after balloon dilatation was still weak; thus, we determined that treatment of the right subclavian artery was also necessary. However, the diameter of the artery near the antecubital fossa was narrow, and the insertion of a large guide catheter was judged to carry a high risk of shunt occlusion. Instead, we decided to approach from the more proximal right brachial artery. Because of the insertion of the 7 Fr guide sheath, we opted for surgical exposure instead of needle puncture to address the problem of hemostasis during extraction. A vascular surgeon exposed the right proximal brachial artery. We then inserted a guide sheath (Destination 7 Fr, 45 cm; Terumo, Tokyo, Japan) through the brachial artery (Fig. 2B). Considering the vessel diameter and any complications such as vessel perforation, we decided to choose a 7 Fr guide-sheath to accommodate stent graft placement. The guide sheath could not be advanced to the front of the lesion due to the meandering course of the subclavian artery; thus, a guide extension (Guidezilla, Boston Scientific, Marlborough, USA) was inserted and advanced to the front of the lesion. A JR4.0 (4Fr, Medikit, Tokyo, Japan) guiding catheter was brought from the left femoral artery to the brachiocephalic artery, which was used as a marker to advance the guide wire (JupiterFC3 300 cm, Boston Scientific). To aid in advancing the guidewire, we used a microcatheter (CorsairPV, ASAHI intecc, Seto, Japan) within the Guidezilla for backup reinforcement. After successful passage across the lesion, the guide wire and microcatheter were rendezvoused to the JR4.0 to create a pull-through system. A balloon (SHIDEN HP 2.5/40 mm, KANEKA, Osaka, Japan) was used for pre-dilatation, and intravascular ultrasound (IVUS) was used to evaluate the inside of the lesion, revealing severe calcification. Consequently, the balloon was sized and re-dilatated using the SHIDEN HP 5.0/40 mm. Because it was difficult to advance the stent to the lesion, the Guidezilla was distally inserted into the lesion once to deliver the stent (SMART 8.0/40 mm, Cordis, Miami, USA). After successful stent placement, post-dilatation was performed using a SHIDEN HP 5.0/40 mm and IVUS confirmed adequate dilatation and crimping of the vessel. The procedure was completed after confirming a good flow on the final angiogram (Fig. 2). In this case, there was severe stenosis in the right common carotid artery. Therefore, to avoid embolization of plaque, devices such as balloons and stents were introduced from the brachial artery, and to the extent that was possible, no devices other than wires and microcatheters were passed from the lower limb arteries to the aorta and brachiocephalic artery. The size of the balloon that was selected was also small enough to prevent the obstruction of the blood flow in the brachiocephalic artery during dilatation. We evaluated the flow in the right subclavian artery using contrast before and after surgery. Ultrasonography after endovascular treatment confirmed that there were no problems with flow. At the end of the treatment, the apical systolic pressure of the sheath implanted in the brachial artery improved from 40 to 100 mmHg. A repeated upper extremity vascular ultrasonogram also showed improved blood flow patterns in the brachial, radial, and ulnar arteries (Table). Symptoms improved after the procedure and had not recurred as of six months after.

Figure 1.

Ultrasonography findings in the subclavian artery. (A) Cross-sectional image. (B) Lateral image. Contrasted computed tomography: (C-E) Subclavian artery occlusion is indicated by arrows. The asterisk indicates the brachial artery site where the incision was made. (F) Stenotic areas of the radial and ulnar arteries.

Figure 2.

Angiographic findings of subclavian artery occlusion. (A) shows the angiogram when approached from the lower extremity, (B) shows the angiogram when approached from the brachial artery. (C) Final contrast after stenting.

Table.

The Time Series of Systolic Velocity of Each Upper Extremity Blood Vessel Is Shown in the Upper Extremity Ultrasonography.

		Pre EVT		Poet EVT		1-month later		6-month later
Subclavian artery		-		154 cm/s		186 cm/s		206 cm/s
Brachial artery		64 cm/s		138 cm/s		171 cm/s		140 cm/s
Radial artery		23 cm/s		38 cm/s		46 cm/s		61 cm/s
Ulnar artery		12 cm/s		44 cm/s		48 cm/s		40 cm/s

EVT: endovascular therapy

Discussion

In this report, we described a case of subclavian artery occlusion in a patient undergoing hemodialysis with a difficult approach that appeared in the arteriovenous fistula side.

As a rule, the indication for the treatment of subclavian artery occlusion is the presence of symptoms (e. g., upper limb ischemic symptoms, vertebrobasilar artery ischemic symptoms, chest pain) and a stenosis of 70% or more. Treatment may also be considered if the difference in blood pressure between the upper extremities is ≥20 mmHg or to ensure peripheral blood flow beyond the stenosis in patients scheduled for hemodialysis arteriovenous fistula construction or coronary artery bypass grafting (CABG). In addition, coronary subclavian steal syndrome, which causes ischemia in the internal thoracic artery graft region after CABG, has been increasingly reported and is attracting attention as a new indication for the treatment of subclavian artery stenosis and occlusion (2). The success rate of treatment is >90%, and restenosis and regurgitation are reported to be less than 20%, making endovascular therapy the first choice of treatment in recent years (3). Nevertheless, complications of subclavian artery catheterization have been reported and include cerebral infarction, stent dropout, and neurological manifestations (4).

As there was no improvement in our patient's symptoms even after taking antiplatelet agents, we planned for catheterization. It is usually advisable to avoid approaching blood vessels near the shunt in patients undergoing hemodialysis because of the risk of arteriovenous fistula vessel damage from physical irritation such as that caused by a sheath. Therefore, in this case, we tried to approach the lower extremity first; however, the tortuous course of the brachiocephalic artery prevented us from advancing the guide catheter sufficiently into the lesion to obtain backup. We therefore had to abandon the approach from the lower extremity. We were able to surgically expose the brachial artery proximal to the arteriovenous fistula, allowing for an ipsilateral approach and avoiding the risk of arteriovenous fistula occlusion. There have been many reports of endovascular therapy approaches to the subclavian artery and reports from the radial, femoral, and brachial arteries at the elbow. Another method is to construct a pull-through system using a bidirectional approach from both the upper and lower extremities to ensure a backup. This case succeeded when the patient gave his consent to surgery after a medical approach alone proved to be too difficult. Because this is only one case, it is necessary to consider whether this method is acceptable for other patients in the future.

In patients with difficult approach sites, such as patients undergoing regular hemodialysis, it is possible to perform endovascular therapy of the subclavian artery with minimal vascular exposure with the aid of a surgeon. We report this information in the hope that it will help clinicians consider this approach as an option in their clinical practice.

Ethical standards: The current paper was approved by the institutional review board of our hospital. Written informed consent was obtained from the patient for publication of this case report and accompanying images.

The authors state that they have no Conflict of Interest (COI).