Endovascular techniques for treating patients with arterial and venous disorders have revolutionized modern medicine by significantly reducing procedure-related morbidity and hospital costs and delivering outcomes better than or, at least in part, equal to those of open surgical procedures. In the past few years, endovascular therapy has expanded from simple dilatation of atherosclerotic lesions to encompass treatment of aneurysmal arterial disease, acute ischemia, arteriovenous malformations, and venous disorders. Such significant advances in endovascular treatment have given physicians and their patients minimally invasive alternatives to major surgical procedures that carry significant morbidity and mortality. This chapter reviews current advances and explores the benefits and limitations in minimally invasive therapies for the treatment of patients with occlusive and aneurysmal disease of the aorta and peripheral vessels.
Endovascular treatment of peripheral vascular disease (PVD) with balloon catheters was first reported by Fogarty and coworkers1 in 1963. The next year, Dotter and Judkins2 introduced the concept of percutaneous revascularization using coaxial-dilating catheters, followed by Grüntzig and Kumpe's3 pioneering work that led to the evolution of percutaneous transluminal angioplasty (PTA).
Since then, dramatic advances in balloon and guidewire technology have made it possible to cross difficult lesions and chronic occlusions. Better-designed stents have revolutionized endovascular interventions, providing an attractive and reliable alternative to vascular surgery to the point that endovascular stents are now the standard of care in peripheral vascular interventions. Marked improvement in immediate- and long-term results with stent grafts now permit minimally invasive treatment of aneurysmal disease of the aorta as well as other major vascular territories. Improvements in pharmacologic agents and in catheter-based thrombectomy devices have made endovascular interventions the first-line therapy in patients who have acute limb ischemia (ALI) caused by thromboembolic disease.
Upper extremity ischemic disease is uncommon, and the majority of cases are secondary to vasospastic disorders, such as Raynaud syndrome and small vessel occlusive disease. In the vast majority of patients who present with chronic symptoms of proximal upper extremity ischemia, atherosclerosis is the underlying cause. Most of these patients are treated medically, with few being candidates for surgical or endovascular therapy.
Subclavian Artery Stenting
Although occlusive disease of the subclavian artery is most often asymptomatic because of the rich supply of brachiocephalic collaterals, when it is symptomatic, patients may present with subclavian steal syndrome (vertebrobasilar symptoms that worsen with exercise or work of the ipsilateral upper extremity); ipsilateral upper extremity claudication; or in patients who have an internal mammary artery bypass graft, coronary-subclavian steal syndrome, in which flow to the graft (left internal mammary artery) becomes compromised, leading to angina or myocardial infarction (MI).
Surgical treatment of patients with subclavian artery stenosis (SAS) is effective, but it carries a mortality rate of approximately 2% and a stroke rate of approximately 3%,4 among other complications. The first subclavian artery angioplasty was reported by Bachman and Kim in 1980,5 and although initial ...