Subclavian angioplasty: Immediate and late results in 50 patients

Catheterization and Cardiovascular Diagnosis 29:8-17 (1 993)

Subclavian Angioplasty: Immediate and Late Results in 50 Patients

Alain Millaire, MD, Manuel Trinca, MD, Philippe Marache, MD, Pascal de Groote, MD, Jean-Louis Jabinet, MD, and Gerard Ducloux, MD

In order to assess the therapeutic outcome of percutaneous transluminal angioplasty for subclavian stenosis, 50 patients were followed up clinically as well as with a velocimetric Doppler after attempted angioplasty. A minimal clinical follow-up of 9 months was ex- pected. Subclavian stenoses were due to atheroma in 49 patients and to Takayasu’s disease in 1 case. Indication of angioplasty was curative in 34 (68%) symptomatic patients (posterior fossa ischemia and/or upper limb ischemia) and preventive in 16 (32%) asymptomatic patients (severe difference of blood pressure between the 2 arms and/or association with carotid stenosis or axillo-femoral bypass). Angioplasty was successful in 45 patients (primary success rate = 90%). Three (6%) thrombosis occurred due to the percutaneous approach, one of the axillary and one of the brachial artery without any significant sequelae, and one of the aorta requiring an aorto-bifemoral bypass. A complication occurred in 2 unsuccessful angioplasties (4%): an ischemic stroke occurred in 1 case and a thrombosis of the dilated site requiring a surgical bypass. Clinical follow-up over a period of %lo1 months (mean = 41) was performed in 43 out of the 45 patients who had undergone angioplasty successfully. Two patients had a follow-up shorter than 9 months: one died after 5 months, the other was lost to follow-up. By the end of the clinical follow-up, 37 (84%) out of the 44 followed-up patients had benefitted from the procedure. Doppler study performed in 35 out of the 44 followed-up patients (80%) over a period of 2-90 months (mean = 39) showed 5 restenosis (14%). This study demon- strates the good long-term results of angioplasty in case of subclavian artery stenosis. Though there are complications, angioplasty could be proposed as a first choice treatment for subclavian stenosis as compared to surgery. Indications in asymptomatic patients should be carefully weighed as complications may occur.

Key words: subclavian angioplasty, subclavian stenosis, steal syndrome

D 1993 wiley-Liss, Inc.

INTRODUCTION

Since the inaugural work of Dotter and Judkins in 1964 [l] and the first balloon angioplasty performed by Griintzig and Hopff in 1974 [2], this technique has known an extensive development.

In 1980, Bachman and Kim [3] published the first case of subclavian angioplasty. Ten years later, more than 420 cases [4] have been reported by different authors. Nev- ertheless, the number of patients in these different series remain small. The follow-up was essentially clinical and over a relatively short period of time without any stan- dardisation. Furthermore, only a few data are available concerning preventive indications of subclavian angioplasty.

AIM OF THE STUDY

The aim of our study was to report initial and long- term results of subclavian angioplasty in our patients who had a minimal follow-up of 9 months. Indication of

angioplasty could be curative or preventive. Follow-up should be clinical combined with velocimetric Doppler.

MATERIALS AND METHODS Patients

Between January 1984 and February 1991 (7 years), subclavian angioplasty was attempted in 50 consecutive patients who had a significant subclavian stenosis (nar-

From the Division of Cardiology and the Division of Radiology H8pital Cardiologique, Centre Hospitalier Regional Universitaire, Lille, France.

Received June 1 , 1992; revision accepted December 2, 1992.

Address reprint requests to Dr. Alain Millaire, Service de Cardiologie C. HBpital Cardiologique, CHRU, 59037 Lille Cedex, France.

Presented in part at the XIIth congress of the European Society of Cardiology, Stockholm, Sweden, September 1990.

0 1993 Wiley-Liss, Inc.

Subclavian Angioplasty 9

vere iliofemoral stenosis or severe tortuosity [5] or after failure of the femoral approach. The stenosis was over- come with a straight floppy tip guide wire (0.032 inches). Angioplasty was performed with a 5 or 6 French balloon catheter. The balloons used had various diame- ters (see Table 111) and a length of 2-4 cm, and were inflated at 4-6 atmospheres during 15-30 sec. In order to avoid embolism in the vertebrobasilar territory, the balloon was placed away from the vertebral ostium (if possible) and the patient was asked to repeat contractions of his hand to increase upper limb blood flow during and immediately after balloon inflation, and thus to maintain or increase the vertebrobasilar steal. Heparin was given intra-arterially during the procedure (5,000 units). Anti- platelet agent (aspirin 100 mg/day or dipyridamole 325 mg/day) was prescribed 24 h before and 3 months after angioplasty . Immediate Technical Results

Angioplasty was considered as successful if residual stenosis was less than 30% of the diameter with a mean transstenotic gradient lower than 10 mm Hg (if the catheter was non-occlusive) and/or a difference of rest blood pressure between the 2 arms lower than 20 mm Hg.

Long-Term Results Long-term results were evaluated on the one hand by

the clinical data: symptoms, measurement of blood pressure on both arms, and clinical consequences of a possible complication following angioplasty. On the other hand, ultrasonic data were collected: static and dynamic Doppler of the subclavian artery was performed to look for significant stenosis and subclavian steal.

Clinical criteria in symptomatic and in asymptomatic patients are listed in Table IV.

Using velocimetric Doppler, stenosis was considered as being significant if the shape of the velocimetric curve was typical and if the difference of rest blood pressure between the 2 arms was higher than 30 mm Hg.

TABLE 1. Presentins Svmotoms of the 50 Patients

No. of uatients %

Symptoms 34 68 Posterior fossa ischemia 14 Upper limb ischemia 13

7 Posterior fossa and upper limb ischemia No symptoms 16 32 Total 50 100

rowing of the diameter of the lumen greater than 50%). Mean age of the 50 patients was 55 2 1 1 years. No significant difference was observed between the mean age of the 38 males (54 years, range 34-73) and of the 12 females (57 years, range 30-75).

Angioplasty was performed for 2 types of indications (see Table I). The indication was either curative in symptomatic patients (as the case of Fig. la), or preventive in asymptomatic patients when the risk of further thrombosis was considered significant and if such a thrombosis could have dramatic consequences:

1 . Cerebral vascularisation was considered as jeopardized in 5 patients because a subclavian stenosis proximal to the vertebral artery was associated with a contralateral or homolateral carotid stenosis. A subclavian steal syndrome was detected in 3 out of these 5 patients.

2. Upper limb vascularisation was considered as jeopardized in 9 patients because of a significant difference in blood pressure between the 2 arms (30-190 mm Hg). This risk was associated with a risk for the cerebral vascularisation (angiographic subclavian steal syndrome) in 3 out of the 9 patients.

3. Lower limb vascularisation was considered as jeopardized in 2 cases because the subclavian stenosis was proximal to an axillo-femoral bypass (Fig. 2a).

In all these 16 asymptomatic cases, the subclavian stenosis was discovered either because a significant difference of rest blood pressure between the 2 arms was observed, or because a vascular murmur was noticed.

The etiology of the stenoses was always atheroma except for one case of Takayasu’s disease. Angiographic findings (anatomic and hemodynamic data) concerning the subclavian stenosis, the involvement of the other extracranial arteries, and the presence of a subclavian steal syndrome are listed in Table 11.

Angioplasty Data concerning the procedure of angioplasty are

listed in Table 111. Subclavian angioplasty was performed under local anesthesia. In some patients, an upper limb approach was used because either the femoral approach was considered as potentially dangerous because of se-

STATISTICS

Data were analysed by means of the Student’s t-test and the chi-square test with the Yates correction. Statis- tical significance was regarded as significant if P < .05. Results are expressed as mean -+ SD.

RESULTS Immediate Results (Table 111)

Among the 39 left subclavian attempted angioplasties , 35 succeeded (Fig. lb) and 4 failed. Failures were due to complete occlusion of the subclavian artery which could not be crossed or to tight stenosis (diameter reduction > 75%). In these particular cases, surgery was secondarily

10 Millaire et al.

Fig. 1. Subclavian angloplasty-curative indication (vertigo). a: Left subclavian stenosis before angioplasty. Vertebral artery is not opacified. b: Angiography after angioplasty: good immediate angiographic result. Opacification of vertebral artery is anterograde and showed a moderate ostial stenosis.

performed in 3 cases (transposition of the left subclavian artery onto the left common carotid and the left subclavian artery in 2 cases) and common carotid artery in 1 case; bypass between the left medical treatment was con- tinued in 1 case. Among the 11 right subclavian at-

tempted angioplasties, 10 succeeded (Fig. 2b) and 1 failed because of a very tight stenosis. Comparison of the degree of stenosis of the 5 technical failures (88.8 ? 1 1.4) with that of the 45 successful angioplasties (67.7 2 10.2) showed a significant difference (P < .01).


Fig. 2. Subclavlan angioplasty-preventive indication (asymptomatic patient). a: Angiography before angioplasty: right subclavian stenosis above an axillo-femoral bypass. b: Angiography after angioplasty: good angiographic result.

12 Millaire et al.

TABLE II. Angiographic and Doppler Findings Before Angioplasty in the 50 Patients

No. of patients

Subclavian stenosis Degree (mean 2 2 SEM): 69.8 ? 12.2% Side:

Left 39/50 (78%) Right 11/50 (22%)

Proximal to the vertebral artery Location:

41 5 1 3

Distal to the vertebral artery Including the origin of the vertebral artery Vertebral artery originating from the aorta

Concomitant involvement (stenosis or thrombosis) of the other extracranial arteries 26/50 (52%)

Contralateral vertebral or subclavian artery 14

Contralateral carotid artery 14 More than 1 artery involved 17

No involvement of other extracranial arteries 24/50 (48%)

Subclavian steal syndrome" 30150 (60%)

"On Doppler or angiography.

Ipsilateral vertebral artery 12

Ipsilateral carotid artery 12

Complications occurred in 5 cases (10%). All these patients had diffuse atherosclerosis. Complications occurred within 3 days after the attempted angioplasty in two patients (4%) in whom angioplasty was unsuccessful. In the first case, an immediate thrombosis of the site of the attempted dilatation occurred. No symptoms occurred, CT scan was normal 6 days later, and the vertebrobasilar steal syndrome was unchanged. A bypass was performed 2 months later between the left common carotid and the left subclavian artery. In the second case, a stroke (hemiplegia) occurred 1 day after the attempted angioplasty and partly resolved during the following days. This stroke was probably ischemic because the CT scan did not show any haemorrhagic signs. The hemiplegia was located on the contralateral side of the angioplasty; it was probably related to the angioplasty because the homolateral carotid was previously occluded. This patient had a vertebrobasilar steal syndrome which was unchanged immediately after the angioplasty . A lupus anticoagulant antibody was previously known.

In 3 other patients (6%), vascular events occurred within 3 months after the successful angioplasty and involved the arterial approach. In the first case, a spasm of the brachial artery occurred during the procedure and resolved after withdrawal of the sheath. A subacute ischemia of the upper limb recurred 10 days after the angioplasty and was related to a brachial thrombosis located at the site of the arterial puncture. Subacute ischemia resolved after medical treatment. In the second case, a large hematoma immediately occurred at the femoral

TABLE 111. Data Concerning the Procedure of Angioplasty in the 50 Patients and the Immediate Results

No. of % patients

Approach Femoral 35/50 70

Upper limb 13/50 26 Femoral (failure) and upper limb 2/50 4

Type of upper limb approach Brachial 6/15 Axillary 9/15

Type of procedures Left subclavian angioplasty 39/50 78

Association with a right Right subclavian angioplasty 11/50 22

vertebral angioplasty 1/50 2 Balloon diameter

8 mm 7 m m 6 mm

Success Failure

Complications

Technical results

Total number Delay after angioplasty

Within 3 days Within 3 months

Subclavian thrombosis Stroke Brachial thrombosis Axillary thrombosis Sub-renal aortic thrombosis

"Number of successful angioplasties.

Type

29/45a 64 3/45 7

13/45 29

45/50 90 5/50 10

5/50 10

2/50 4 3/50 6

puncture site. Antiplatelet agents were not prescribed. Twenty days after angioplasty, the patient complained of severe intermittent claudication. Angiography showed a bilateral iliac and a sub-renal aortic thrombosis with large collateral arteries. In this particular patient who had severe diffuse atherosclerosis, indication of angioplasty was preventive. An aorto-bifemoral bypass was successfully performed. In the third case (patient with Takaya- su's disease), an asymptomatic axillary thrombosis was detected on a systematic angiography which was performed 3 months after the angioplasty.

The complications occurred in 2 out of the 37 cases of femoral approach (5%), in 3 out of the 9 cases of axillary approach (33%), and in 1 out of the 6 brachial approaches (12%). The differences were not significant.

In the case with a combined subclavian angioplasty associated with a vertebral angioplasty (the stenosis of the vertebral artery was ostial, concentric, severe [go%], and located in a bend; the balloon was 6 mm large), intimal dissection occurred followed by a complete thrombosis of the proximal vertebral artery without ob-


TABLE IV. Clinical and Velocimetric Doppler Criteria Used in the Studv

Symptomatic patients Asymptomatic patients Clinical results Symptoms D B P Complicationsb D B P Complicationsb Very good none <20 none < 20 none Good improved <or>20 none <30 none

Poor not improved or recurrence <or>20 yes or none >30 or ischemic events' yes or none Moderate improved <or>20 Yes <30 Yes

"DBP = difference of systolic blood pressure between the two arms (mm Hg). bComplications of the procedure of angioplasty . 'Ischemic events during the follow-up in the same arterial territory as that of angioplasty.

vious functional consequence. Distal vertebral artery was reinjected by collateral arteries. This complication was related to the vertebral angioplasty and not to the subclavian angioplasty .

Long-Term Results (Table V) All patients had a clinical follow-up longer than 9

months except 2 patients. One patient died 5 months after the procedure (stroke in the carotid territory) and 1 was lost to follow-up after 6 months (good clinical result at 6 months).

Ten patients out of the 45 successful angioplasties were not controlled by means of Doppler including the 2 patients who had a clinical follow-up shorter than 9 months. The other 7 patients had a good or a very good clinical result at the end of the clinical follow-up.

Among the 5 patients who had a restenosis on Doppler examination, 3 had a poor clinical result and only 1 of them had accepted an angiographic control. Restenosis was confirmed, a second angioplasty was successfully performed 7 months after the first one with a good long- term result. The 2 other patients maintained a beneficial clinical effect.

Comparison of the group with curative indications and the group with preventive indications is reported in Table VI. No significant difference was found except for the number of patients with subclavian steal syndrome. Comparison of the clinical results was not performed because criteria were different in symptomatic and asymptomatic patients.

The reasons for achieving poor results (at the end of the clinical follow-up) were identified in only 2 patients who had restenosis signs on Doppler control. In the 5 remaining patients with poor clinical result, no reason can be really identified either because the Doppler follow-up was not performed or it was too short (3 patients), or because other localizations of atherosclerosis (2 patients) may have participated in the clinical result.

DISCUSSION

Our data confirms the good initial and long-term results of subclavian angioplasty .

TABLE V. Long-Term Results of the 45 Patients With Successful Angioplasty

Duration of follow-up Clinical follow-up Doppler follow-up

Clinical follow-up 44/45" (98%) Doppler follow-up 35/44 (80%)

Clinical results

2:} 37/44 (84%) Very good Good Moderate 4 Poor 7/44 (16%)

No restenosis 30135 (86%) Restenosis 5/35 (14%)

41.2 months (range 9-101) 39.5 months (range 1-90)

Number of followed-up patients

Doppler results

"Number of successful angioplasties.

Technical failures of our series could be related to the high degree of stenosis. All stenoses in which angioplasty failed were severe ones (> 75%). The mean stenosis degree of the unsuccessful angioplasties was sig- nificantly different than that of successful angioplasties. Similar failure rates have been reported in the literature [6-91 in case of occlusion. Procedures other than balloon angioplasty should be proposed in such cases (surgery or other interventional techniques). Nevertheless, some re- cent papers reported cases of successful balloon procedures [ 10-121.

Our complication rate is comparable but slightly higher (Table VII) than those previously reported rates [13,14]. The main series (number of patients > 20) of the literature [4,7,13-171 were taken into account for this comparison. Our careful follow-up could explain this higher frequency since 2 of the 5 complications were asymptomatic. Thrombosis of the upper limb approach secondary to the arterial puncture is the most frequent complication. It occurred in 6 out of the 56 upper limb approaches reported in Table VII [4,13,14,16,17]. The high frequency (10.7%) of this type of complication did not appear preventable by a surgical approach [ 161. Dis- tal embolization could be ruled out in our 2 cases because thrombosis occurred at the exact site of the arterial

14 Millaire et al.

TABLE VI. Comparative Data of the Group of 34 Patients With Curative Indication and the Group of 16 Patients With Preventive Indication of Subclavian Angioplasty

Indication

Curative Preventive P Patients

No. 34/50 (68%) 16/50 (32%) Age (years) 55.1 2 11.1 53.7 ? 11.9 NS

Degree of stenosis (%) 70.8 .+. 12.7 67.6 2 10.4 NS No. of patients with other extracranial arteries stenosis 17/34 (50%) 9/16 (56%) NS No. of patients with subclavian steal 24/34 (71%) 6/16 (37.5%) <.05

No. of technical failures 5/34 (15%) 0116 (0%) NS No. of complications 4/34 (12%) 1/16 (6%) NS

No. of followed-up patients 28/29 (97%) 16/16 (100%) NS Duration (months) 40.8 f 28.2 42.1 ? 27.4 NS Late results:

Benefit' 27/28 (96%) 10/16 (62.5%) * Poor 1/28 (4%) 6/16 (37.5%) *

No. of follow-up patients 24/28 (86%) 11/16 (69%) NS Duration (months) 40.1 ? 26.0 38.6 2 26.5 NS No. of restenosis 3/24 (12.5%) 2/11 (18%) NS

Angiographic findings

Early results

Clinical follow-up

Doppler follow-up

"Clinical benefit = very good, good, or moderate results. *No comparison because criteria were different in the 2 groups. NS = not statistically significant.

TABLE VII. Immediate Results of Subclavian Angioplasties-Main Series (> 20 patients)

Primary Number of No. of No. of Death success Complications upper limb patients upper limb rate rate rate approach

References andPTA" approaches (%) (%) (%) thrombosis

Burke et al. [15] 27/30 15 0 90 7.4 0 Dorros et al. [I61 27/33 27 0 100 7.4 2 Diiber et al. [4] 22/23 2 0 91 4.5 Ib Erbstein et al. [17] 24/? 6 0 88 4.2 1 Farina et al. [13] 21/23 5 0 90 9.6 1 Hebrang et al. [I21 52/52 3 0 86.5 ? ? Motarjeme et al. [7] 22/23 ? 0 13 0 0 Wilms et al. [I41 22/23 1 0 92 9 1

6 Total 217/? 59 Our study 50150 15 0 93 10 2

"PTA = percutaneous transluminal angioplasty. hStenosis.

- - -

puncture. Lower limb approach thus appears to carry a lower risk but rare occurrence of complications is still possible [4,18]. Cerebral embolism occurred in 1 of our cases who had a vertebrobasilar steal syndrome. Such cases were previously described [6,8,15]. In case of vertebrobasilar steal syndrome, the low frequency of cerebral embolism could be explained by the delay (20 sec to a few min) observed in the return to an anterograde vertebral flow [ 8,191. Among the 426 subclavian angioplasties reported in the literature [4], no mortality was observed.

Immediate results of surgical series [20-281 have seen their mortality rate decreased with the use of the extrathoracic approach (Table VIII). In case of transthoracic approach, mortality rate was higher than 5.4% and complication rate was high (between 18.7% [23] and 50% [22]). With extrathoracic approach (supra-clavic- ular transversal cervicotomy) mortality rate was always lower than 5.4% but complication rate remains most of- ten high (between 19% [22] and 23% [24]). Compared to angioplasty, the higher risk of surgery may be due to the necessity of performing a general anesthesia on patients


TABLE VIII. Immediate Results of Suraerv in Case of Subclavian Arterv Stenosis

References Year of

Dublication

Diethrich et al. [20] Crawford et al. [21] Fields and Lemak [22] Thompson et al. [23] Beebe et al. [24] Raithel [25] Vogt et al. [26] Burnay et al. [27] Branchereau et al. [28]

1967 1969 1972 1980 1980 1980 1982 1983 1991

No. of patients

125 26 1 168 81 35 67 20 89 97

Transthoracic approach

Mortality Complications rate (%) rate (%)

- -

5.4 ? 8 50

18.7 18.7 ? 23 6.7 16.7

14.7 ? 0 23= - -

Extrathoracic approach

Mortality Complications rate (%) rate (%)

4.8 ? 2.3 ?

? 19 1.2 ? 0 23 0 0 0 ? 0 23" 1 4

"Type of approach non-specified.

who frequently have diffuse atheroma (cerebrovascular and/or coronary artery disease) and sometimes respira- tory failure due to smoking. Nevertheless, surgery remains mandatory in case of complete occlusion, since balloon angioplasty gave poor results in such cases [6-

Long-term results of subclavian angioplasties are reported in Table IX. These series are usually smaller and long-term follow-up shorter [4,7,12,14-17,291 than in our study. Systematic velocimetric control was performed in 2 previous series [12,13]. Our results are roughly similar, with 84% of clinical benefit and 86% of the controlled patients having no velocimetric signs of restenosis. Restenosis rate of subclavian artery is similar with angioplasty as compared to surgery [26].

As proposed by other authors [13-16,29,30] subclavian angioplasty was performed in our series in some asymptomatic patients. To report that some patients are asymptomatic is particularly difficult in case of posterior fossa ischemia because symptoms are intermittent, non- specific [31,32], and are related to the carotid distribu- tion in 20% of the cases [33]. No correlation was previously observed between symptoms and degree of stenosis [22,28] or between symptoms and hemodynamic data [28]. Additional factors may influence the presence or absence of symptoms such as the adequacy of collateral circulation and concomitant lesions of other extracranial arteries [22,28].

In asymptomatic patients, the problem of the decision of performing a preventive angioplasty appears different according to the presence or the absence of other localizations of atherosclerosis combined with the subclavian stenosis. When the subclavian stenosis is associated with other atherosclerotic localizations, the management appears not to be very controversial. Thus, the treatment of asymptomatic subclavian stenosis in the case of axillary- femoral bypass or internal mammary bypass graft is gen- erally recommended [14-16,34,35]. On the other hand, prognosis is worsened when combined atherosclerotic

91.

lesions impair the carotid as well as the vertebral circulation. Impairment of the vertebral circulation by a subclavian steal increases by 6 times the stroke risk of patients with atherosclerosis of the carotid system [36]. Thus, some authors consider that restoration of blood flow in case of a prevertebral subclavian artery stenosis might diminish the risk of stroke when carotid stenosis develops [37]. When the subclavian artery stenosis (with steal syndrome) is the single atherosclerotic localization, management remains more controversial especially as there is no data bank concerning the natural history of subclavian artery disease comparable to that available for asymptomatic internal carotid artery disease [38]. In- deed, some physicians consider that the subclavian steal syndrome is a harmless syndrome in asymptomatic patients [39] because the risk of stroke appeared low (no stroke occurred during a mean follow-up of 2 years in the study of Bornstein). However, certain data should be considered before decision making. Severe ischemic events (stroke or severe ischemia with tissue loss of the hand or digits) may directly be the presentation of the disease without premonitory clinical signs and transient ischemic events [22,40,41]. When the ischemic event occurs in the vertebrobasilar territory, the presence of a subclavian steal syndrome appears as a worsening factor because the reversal vertebral blood flow may increase the size of the ischemic territory by changing the ischemic penumbra into an infarcted tissue [42]. Finally, when a subclavian stenosis progresses to a complete occlusion of the artery, the success rate of angioplasty is very much lower than in the case of a stenosis [34,43].

The lack of zero risk in our asymptomatic patients emphasizes that indication of subclavian has to be very selective. Our overall complication rate is similar to that observed in other series but it is not insignificant (10%). It was worsened by the larger number of patients in our series as compared to our previous reports [44]. Further- more, a complication requiring a surgical treatment occurred in 1 of our 16 asymptomatic patients. On the other

16 Millaire et al.

TABLE IX. Long-Term Results of Subclavian Angioplasties-Main Series (> 20 attempted angioplasties)

Follow-up Results No. of patients Mean Frequency of Frequency of followed-uplno. duration restenosis functional

References of angioplasties” (months) (%) benefit (%)

Dorros et al. [16] 221 28 9 95 Duber et al. [4] 19/21 34 10 ? Erbstein et al. [171 24/24 ? 12 83 Farina et al. [13] 19/19 30 16 89 Hebrang et al. [12] 45/52 29 9 80

Wilms et al. [14] 18/22 25 13.5 82

Our study (clinical data) 44/45 41.2 16 84 Our studv (velocimetric data) 34/45 39.4 15

Motarjeme et al. [7] 16/22 27 0 ?

-

”Successful angioplasties

hand, in view of the surgical-risk, surgery is seldom performed in such asymptomatic patients [27]. Thus, preventive indications should be carefully selected and if treatment is decided, angioplasty should be preferred to surgery.

CONCLUSION

Initial and long-term efficiency of subclavian angioplasty is corroborated by our clinical and velocimetric Doppler data. Such results can be accounted for by performing angioplasty as an initial therapy in case of subclavian stenosis. A very careful selection of the asymptomatic cases has to be performed.

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Subclavian angioplasty: Immediate and late results in 50 patients

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