Endovascular therapy of axillary artery disease with drug-coated balloon angioplasty

Abstract

The occurrence of upper-extremity arterial disease is less common than that of the lower extremities. Nevertheless, exercise-induced symptoms, when present, can significantly affect functional capacity and limit quality of life. We report a case of exertional right upper-extremity pain and severe right axillary artery disease that was revascularized using an off-label drug-coated balloon technology with resolution of symptoms.

Clinical manifestations of upper-extremity arterial disease tend to be distinct from those of lower-extremity disease, given the abundance of collateral circulation (1, 2). The main focus in managing upper-extremity arterial disease is treatment of preexisting cardiovascular risk factors with aggressive medical therapy and lifestyle modification. When refractory symptoms ensue, surgical or percutaneous revascularization should be considered. Surgery with bypass grafts has been associated with improved patency compared to endovascular therapy, but with comparable complication rates (3). When endovascular therapy is considered, the preferred method remains controversial (4, 5). We present a patient with symptoms of right upper-extremity claudication and likely obstructive atherosclerotic disease of the axillary artery who underwent successful revascularization using drug-coated balloon angioplasty with subsequent resolution of symptoms.

CASE REPORT

A 66-year-old woman presented with right arm claudication. She had a prior history of hypertension, hyperlipidemia, pulmonary sarcoidosis, rheumatic heart disease, atrial fibrillation, and a permanent pacemaker for tachy-brady syndrome. She had extensive atherosclerotic disease with known nonobstructive coronary and carotid artery disease and previous percutaneous revascularization for peripheral arterial disease. The patient had been maintained on aspirin and clopidogrel.

She presented with progressive symptoms of right arm discomfort, aggravated by exercise and heavy-object lifting. Examination disclosed a 40 mm Hg systolic blood pressure differential between the upper extremities and a diminished right radial pulse. Ultrasound of the upper extremities demonstrated severe right and moderate left axillary artery disease. Computed tomographic (CT) angiography confirmed the ultrasound findings and showed multifocal obstructive atherosclerotic lesions of the axillary arteries bilaterally. Serologic studies had been negative for an underlying inflammatory and/or autoimmune process with the exception of a mildly elevated erythrocyte sedimentation rate. The patient underwent upper-extremity angiography, confirming the sonographic and CT angiography findings (Figure 1a). Given optimal medical therapy and refractory right arm claudication, the patient opted for endovascular therapy.

Figure 1.

Digital subtraction angiography images (a) before intervention, showing diffuse, obstructive atherosclerotic disease in the right axillary artery, and (b) after treatment with drug-coated balloon angioplasty.

A 6Fr 90 cm Cook sheath was advanced via the left common femoral artery into the right brachiocephalic trunk for endovascular intervention using standard sheath delivery techniques. Unfractionated heparin with a goal partial thromboplastin time of 250 to 300 seconds was given. The lesions in the axillary artery were crossed using a 0.018˝ gold-tip Glidewire (Terumo Medical Corp., Somerset, NJ). The 0.018˝ glidewire was exchanged for a supportive 0.035˝ SupraCore wire (Abbott, Chicago, IL). The right axillary artery lesions were subsequently predilated with a 4.0 mm × 40 mm Armada balloon (Abbott, Chicago, IL), followed by drug-coated balloon angioplasty with an IN.PACT Admiral 4.0 mm × 120 mm balloon (Medtronic, Minneapolis, MN). Postintervention angiography revealed excellent luminal expansion without evidence of flow-limiting dissections (Figure 1b). Postprocedurally, the patient reported resolution of her right upper-extremity symptoms, and the blood pressure differential had resolved. At 6- and 12-month follow-up, she remained asymptomatic, with 2+ right brachial, radial, and ulnar pulses.

DISCUSSION

Given the rarity of atherosclerotic axillary artery disease, most data on short- and long-term outcomes following percutaneous transluminal angioplasty (PTA) and/or stenting of focal upper-extremity atherosclerotic disease are extrapolated from subclavian artery revascularization (6) (Table 1). In a retrospective study evaluating outcomes in 274 patients treated with either a conservative (n = 165) or invasive (n = 109) approach for subclavian artery atherosclerotic disease with a median follow-up of 42 months, patients treated with PTA had a 60% risk reduction for the development of a hemodynamically significant stenosis (P < 0.01), defined as an upper-extremity blood pressure differential of ≥20 mm Hg compared with conservative treatment (7).

Table 1.

Summary of published data on patency rates of upper-extremity revascularization

First author (Ref)	Year	Number of patients/narrowings	Follow-up in months	Narrowest artery	Revascularization	Patency
Lowman (11)	1983	10/10	13	Subclavian and innominate	PTA	90%
Wilms (12)	1987	22/23	25	Subclavian	PTA	82%
Burke (13)	1987	27/30	36	Subclavian, innominate, and vertebral	PTA	NA
Cook (14)	1989	6/6	18	Subclavian	PTA	83%
Jaschke (15)	1989	12/12	12	Subclavian, innominate, and axillary	PTA	91%
Qi (16)	1991	125/125	46	Subclavian and vertebral	PTA	99%
Hebrang (17)	1991	52/52	29	Subclavian	PTA	91%
Perrault (18)	1993	11/11	38	Subclavian	PTA	100%
Millaire (19)	1993	50/50	41	Subclavian	PTA	86%
Kumar (20)	1995	27/31	NA	Subclavian	Stent	NA
Motarjeme (21)	1996	112/151	60	Innominate, subclavian, carotid, and vertebral	PTA	97%
Martinez (22)	1997	17/17	19.4	Subclavian	Stent	81%
Rodriguez-Lopez (9)	1999	69/70	13	Subclavian	Stent	73%
Körner (23)	1999	37/43	15	Subclavian and innominate	PTA	72%
Schillinger (24)	2001	115/115	44	Subclavian	PTA ± stent	59%
González (25)	2002	9/9	37.4	Subclavian	PTA	89%
Angle (26)	2003	21/21	27	Subclavian	PTA ± stent	79%
Modarai (3)	2004	41/41	48	Subclavian and innominate	PTA ± stent	82%
Amor (27)	2004	86/89	42	Subclavian	Stent	81%
De Vries (5)	2005	110/110	34	Subclavian	PTA ± stent	88%
Filippo (28)	2006	42/42	60	Subclavian	Stent	71%
Przewlocki (29)	2006	75/76	24.4	Subclavian and innominate	PTA ± stent	77%
Sakai (30)	2007	26/28	6	Subclavian	Stent	100%
Abu Rahma (31)	2007	121/121	41	Subclavian	PTA ± stent	70%
Van Noord (32)	2007	43/43	12	Subclavian and brachiocephalic	PTA ± stent	76%
Linni (33)	2008	40/40	50.1	Subclavian	Stent	95%
Sixt (4)	2009	107/108	12	Subclavian and brachiocephalic	PTA ± stent	88%
Yu (34)	2010	14/14	12	Subclavian	Stent	93%
Wang (35)	2010	59/61	40.7	Subclavian	Stent	85%
Song (36)	2012	148/148	67	Subclavian	Stent	49%
Babic (37)	2012	56/56	40	Subclavian	Stent	83%
Li (38)	2013	71/71	27	Subclavian	Stent	85%
Higashimori (39)	2013	59/60	49	Subclavian	Stent	86%
Almeida (40)	2014	16/16	12	Subclavian	Stent	100%
Che (41)	2016	167/167	60.6	Subclavian	Stent	87%

NA indicates not available; PTA, percutaneous transluminal angioplasty.

Improvements in stent technology, coupled with widespread use, paved the way for studies evaluating the efficacy of stenting in upper-extremity vessels. An initial study by Sueoka et al (8) evaluated the efficacy of balloon-expandable stents in treating proximal subclavian artery stenosis causing subclavian steal syndrome after failure of an initial approach with PTA, with a procedural success rate of 100%. Subsequent studies by Rodriguez-Lopez et al (9) and Henry et al (10) demonstrated good short- and mid-term patency rates, with similar long-term patency rates compared with PTA. A recently published meta-analysis of 35 noncomparative studies with 1726 patients examining PTA and stenting in subclavian arterial occlusive disease found that technical success rates were higher in stented patients, without a statistical difference in rates of symptom resolution and long-term primary patency rates (6). We report the first case of symptomatic axillary artery disease successfully treated with off-label drug-coated balloon angioplasty and resolution of symptoms postprocedurally.