title: Subclavian steal: Endovascular treatment of total occlusions of the subclavian artery using a retrograde transradial subintimal approach.
abstract: BACKGROUND
  In symptomatic subclavian steal syndrome, endovascular treatment is the first line of therapy prior to extra-anatomic surgical bypass procedures. Subintimal recanalization has been well described in the literature for the coronary arteries, and more recently, in the lower extremities. By modifying this approach, we present a unique retrograde technique using a heavy tip microwire to perform controlled subintimal dissection.
  
  
  METHODS
  We present two cases of symptomatic subclavian steal related to chronic total occlusion of the left subclavian artery and right innominate artery, respectively. Standard crossing techniques were unsuccessful. Commonly at this point, the procedures would be aborted and open surgical intervention would have to be pursued. In our cases, retrograde access was easily achieved via an ipsilateral retrograde radial artery, using controlled subintimal dissection and a heavy-tipped wire.
  
  
  RESULTS
  We were able to easily achieve recanalization in both attempted cases of chronic total occlusion of the subclavian and innominate artery, using a retrograde radial subintimal approach. Subsequent stent-supported angioplasty resulted in complete revascularization. No major complications were encountered during the procedures; however, one patient did develop thromboembolic stroke secondary to platelet aggregation to the stent graft, 9 days post-procedure.
  
  
  CONCLUSIONS
  Endovascular treatment is considered the first-line intervention in medically refractory patients with symptomatic subclavian steal syndrome. In the setting of chronic total occlusions, a retrograde radial subintimal approach using a heavy tip wire for controlled subintimal dissection is a novel technique that may be considered when standard approaches and wires have failed.
authors: Christiana Care Health System, Newark, DE, USA ssatti@christianacare.org.
authors: Sudhakar R
authors: SR
authors: Satti
authors: Christiana Care Health System, Newark, DE, USA.
authors: Sohil N
authors: SN
authors: Golwala
authors: Christiana Care Health System, Newark, DE, USA.
authors: Ansar Z
authors: AZ
authors: Vance
authors: Christiana Care Health System, Newark, DE, USA.
authors: Sonya N
authors: SN
authors: Tuerff
mesh_terms: D003937:Diagnosis, Differential; D057510:Endovascular Procedures / Q000295:instrumentation*; D005260:Female; D006801:Humans; D008875:Middle Aged; D013348:Subclavian Artery; D013349:Subclavian Steal Syndrome / Q000000981:diagnostic imaging* / Q000628:therapy*; D016896:Treatment Outcome
keywords: Angioplasty; artery occlusion; case study; chronic total occlusion; innominate artery; retrograde access; stent; stroke risk; subclavian artery; subclavian steal syndrome; subintimal dissection; subintimal recanalization