Abstract
Background
Radiation-induced atherosclerosis represents an underestimated clinical entity.
Case Summary
We report on 2 cases of patients with upper-limb ischemia due to subclavian artery lesions. Both patients had radiation therapy due to cancer more than 15 years before symptom onset and no other signs of atherosclerosis. Angiography and intravascular ultrasound were performed in both cases, and lesions were treated with angioplasty and stent placement in the first patient, whereas intravascular lithotripsy was necessary in the second patient due to severe calcification and balloon underexpansion.
Discussion & Take-Home Messages
Intravascular ultrasound helps to accurately assess lesion characteristics, size the balloon and stent devices, and judge the effectiveness of the endovascular therapy. Since radiotherapy is linked to accelerated atherosclerosis, such patients may benefit from clinical and imaging surveillance by duplex ultrasound.
Key words: axillary arteries, intravascular ultrasound (IVUS), radiation-induced arteriopathy, subclavian, upper extremity peripheral artery disease
Graphical Abstract
History of Presentation
Two 70- (Patient #1) and 71-year-old (Patient #2) female patients were referred due to right subclavian artery stenosis and left subclavian artery occlusion, respectively. Patient #1 had intermittent claudication and a small trophic ulcer of her right first digit. Patient #2 also had intermittent claudication of her upper limb.
Past Medical History
Both patients had radiation therapy due to cancer more than 15 years before symptom onset and no other signs of relevant atherosclerosis. Patient #1 received radiation therapy due to tonsil carcinoma with lymph node metastases 15 years prior. Patient #2 received radiation therapy due to left-sided breast cancer 20 years prior.
Differential Diagnosis
Both patients were examined by duplex ultrasound of their carotid and lower-limb arteries, and no signs of relevant atherosclerosis were found.
Investigations and Management
Angiography with adjunctive intravascular ultrasound (IVUS) examination showed a subtotal occlusion of the right proximal subclavian artery (red arrowheads in Figure 1A) due to mixed atheromatous appearance on IVUS (§, noncalcified, partly fibrotic and ∗, calcified components in B) in patient #1. The lesion was treated by angioplasty and a bare-metal (BM) stent (Dynetic 7.0∗18 mm, Biotronik) (Figures 1C and 1D).
Figure 1.
Angiographic and IVUS Images of Our Patients
Angiography and intravascular ultrasound showed a subtotal occlusion of the right proximal subclavian artery due to mixed atheroma (A and B). Red arrow in (A) pointing to high grade stenosis by angiography; and red arrow in (B) pointing to soft plaque and asterisk depicting calcified plaque component. The lesion was treated by angioplasty and a bare-metal stent with a good result by angiography and IVUS (C and D). With the second patient, angiography demonstrated occlusion of the distal subclavian (E), whereas fluoroscopy revealed massive lesion calcification (F). Red arrows in (F) depicting severe calcification; blue arrow in (F) showing the IVUS catheter. During balloon angioplasty, a “waist” was present, indicating incomplete expansion (G). Red arrows in (G) indicating incomplete expansion of the conventional balloon. Intravascular lithotripsy was therefore used, facilitating better balloon expansion (H) and a good angiographic result after the implantation of a self-expanding bare-metal stent (I). Red arrows in (H) indicating complete expansion of the lithotripsy balloon.
In patient #2, angiography showed occlusion of the distal subclavian at the transition to the axillar artery, with distal filling by collateral vessels (∗, depicting the origin of the collateral in E, Video 1). Fluoroscopy revealed massive calcification (red arrowheads in F, blue arrowhead at the distal end of IVUS catheter). Balloon angioplasty demonstrated a “waist,” that is incomplete lesion expansion (arrowheads in G). IVUS imaging confirmed severe, partly circumferential lesion calcification (Video 2), and adjunctive intravascular lithotripsy (IVL) was subsequently required to better dilate the lesion (5.0 × 60 mm IVL balloon, Shockwave Medical, Kleve, shown in H and in Video 3). In addition, drug-coated balloon angioplasty was performed using a 5.0∗120-mm balloon (Ranger, Boston Scientific). IVUS was again performed, demonstrating vessel recoil (Video 4); as such, a self-expanding BM stent (6.0∗60 mm LifeStent, BD, Heidelberg) was implanted. After postdilation (with a 5.0-mm noncompliant balloon), adequate stent expansion was observed (I, Video 5), albeit with some persistent deformity of the stent by IVUS (Video 6).
Outcomes and Follow-Up
The further clinical course was uneventful with both patients, and duplex scans revealed triphasic flow signals in downstream arteries with full resolution of symptoms during 4 weeks of follow-up.
Discussion
Upper-extremity peripheral artery disease is more frequent than anticipated, most often due to atherosclerosis involving the ostial or proximal vessels.1 Radiation-induced arteriopathy represents an underestimated clinical entity, which is increasing in frequency due to improving survival after cancer treatment and with the aging population.2 In the two cases reported herein, both the distal lesion location and the use of IVUS, which is recommended, especially in complex anatomy,3 helped detect radiation-induced atheroma with various grades of lesion calcification and complexity. In cases with severe calcification, treatment becomes challenging, making the use of advanced crossing and/or lesion preparation techniques necessary.4,5
Current guidelines encourage endovascular revascularization in patients with symptomatic subclavian artery stenosis, despite similar long-term outcomes, due to lower complication rates.6 In the first patient, balloon angioplasty was performed, followed by the placement of a short balloon-expandable BM stent. A balloon-expandable stent was chosen due to the short length and low complexity of the lesion and its location in the mid part of the subclavian artery, which is less mobile than the distal part of the artery due to its position behind the fixed scalene muscles. In the second patient, a self-expanding nitinol stent was deployed after lesion preparation using IVL. In this case, a self-expanding stent was chosen, due to lesion location in the distal part of the subclavian extending to the axillar artery. This segment is mobile, as it traverses the chest, going beneath the clavicle and over the first rib to reach the axilla. Due to lesion complexity and the higher risk of restenosis, drug-coated balloon was performed in this case prior to stent placement. Drug-eluting stents, on the other hand, have shown better patency rates than BM stents in the femoropopliteal segment.7 However, data on the use of drug-eluting stents in the subclavian artery is scarce. Due to the high risk of restenosis in patients with prior radiation, both patients will be scheduled for routine duplex ultrasound every 6 months.
Conclusions
Clinicians need to be aware of such rare entities to facilitate optimal patient treatment and prevent potential complications when endovascular revascularization is warranted. If endovascular therapy fails, surgical revascularization with a carotid-subclavian bypass graft represents a viable alternative option. In addition, since radiotherapy is linked to accelerated atherosclerosis, such patients may benefit from imaging-guided surveillance.
Data Availability Statement
The data that supports the findings of this study is available on reasonable request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.
Take-Home Messages
-
•
Intravascular ultrasound helps to accurately assess lesion characteristics, size the balloon and stent devices, and judge the effectiveness of the endovascular therapy.
-
•
Since radiotherapy is linked to accelerated atherosclerosis, such patients may benefit from clinical and imaging surveillance by duplex ultrasound.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Total Occlusion of the Distal Subclavian at the Transition to the Axillar Artery, With Distal Filling by Collateral Vessels in Patient #2
Baseline Intravascular Ultrasound Scan in Patient #2
Balloon Angioplasty of the Severely Calcified Occlusive Lesion, Using a 5.0 × 60-mm Intravascular Lithotripsy (IVL) Balloon in Patient #2
Intravascular Ultrasound After Lesion Preparation Using Intravascular Lithotripsy in Patient #2
Final Angiographic Result After Intravascular Lithotripsy, Self-Expanding Stent Placement, and High-Pressure Postdilatation in Patient #2
Final Intravascular Ultrasound Run Using Chroma Mode for Flow Assessment in Patient #2
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Total Occlusion of the Distal Subclavian at the Transition to the Axillar Artery, With Distal Filling by Collateral Vessels in Patient #2
Baseline Intravascular Ultrasound Scan in Patient #2
Balloon Angioplasty of the Severely Calcified Occlusive Lesion, Using a 5.0 × 60-mm Intravascular Lithotripsy (IVL) Balloon in Patient #2
Intravascular Ultrasound After Lesion Preparation Using Intravascular Lithotripsy in Patient #2
Final Angiographic Result After Intravascular Lithotripsy, Self-Expanding Stent Placement, and High-Pressure Postdilatation in Patient #2
Final Intravascular Ultrasound Run Using Chroma Mode for Flow Assessment in Patient #2
Data Availability Statement
The data that supports the findings of this study is available on reasonable request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions.
Take-Home Messages
-
•
Intravascular ultrasound helps to accurately assess lesion characteristics, size the balloon and stent devices, and judge the effectiveness of the endovascular therapy.
-
•
Since radiotherapy is linked to accelerated atherosclerosis, such patients may benefit from clinical and imaging surveillance by duplex ultrasound.