title: Endovascular recanalization of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and an argument for embolic protection.
abstract: OBJECTIVE
  We described our endovascular techniques for the recanalization of chronic occlusions of the brachiocephalic and subclavian arteries. Given their large caliber, origins from the aorta, and proximity to the carotid and vertebral arteries, various complex endovascular techniques are required to achieve revascularization. Navigation of distal embolic protection devices into the carotid and vertebral arteries mandates varied catheter approaches.
  
  
  METHODS
  Four women harboring chronic occlusions of the brachiocephalic and subclavian arteries were evaluated for their presenting symptoms, neurologic status, endovascular treatment, complications, and radiographic and clinical follow-up. We reviewed three specific treatment scenarios and analyzed predictive factors associated with treatment failure.
  
  
  RESULTS
  Three chronic occlusions of the subclavian artery and 1 chronic occlusion of the brachiocephalic artery were identified in the four patients. All patients previously had experienced a stroke in the affected vascular territory or transient ischemic attacks from steal syndromes. Three target vessels were reopened successfully with angioplasty and stenting. In all cases, distal embolic protection devices were used, and multiple access points, including radial, brachial, and femoral catheterization, were required. Angiographic follow-up (range, 6-18 months) demonstrated stable patency of the stents in the three successfully treated patients. There were no transient or permanent complications.
  
  
  CONCLUSIONS
  Endovascular recanalization of the great vessels with the use of distal embolic protection devices requires multiple catheters and complex endovascular techniques but is feasible and safe. A significant percentage of these occlusions can likely be reopened through endovascular techniques.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address: Neuropub@chw.edu.
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Azam
authors.initials: A
authors.lastname: Ahmed
authors.forename: Alim
authors.initials: A
authors.lastname: Mitha
authors.forename: Michael
authors.initials: M
authors.lastname: Stiefel
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000601:surgery*; D016122:Brachiocephalic Trunk / Q000601:surgery*; D002533:Cerebral Angiography; D016208:Databases, Factual; D004621:Embolization, Therapeutic / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015607:Stents; D013349:Subclavian Steal Syndrome / Q000601:surgery*