Management Of Innominate Artery Stenosis With Retrograde Hybrid Approach Utilizing Shockwave Intravascular Lithotripsy And A Flow Reversal System
Maksim V. Gusev, MD, Theodore Teruya, MD, Kristyn Mannoia, MD, Sheela Patel, MD, Allen Murga, MD, Ahmed Abou-Zamzam, MD.
Loma Linda University, Loma linda, CA, USA.
DEMOGRAPHICS: We present a case of an 82 year-old female with hypertension, type 2 diabetes, depression, arthritis, history of atrial tachycardia status post ablation in 2013.
HISTORY: The patient was referred to our vascular clinic by her ophthalmologist who noted evidence of right retinal artery occlusion with dizziness and vestibular migraines diagnosed by neurology and right upper extremity exertional fatigue. Work up revealed severe innominate artery stenosis . Duplex ultrasound of the neck showed flow reversal in the right vertebral artery and low flow in the right subclavian and common carotid arteries. Left side was unremarkable.
PLAN: Patient was consented for angiogram with plan for Shockwave Intravascular Lithotripsy in open retrograde fashion utilizing ENROUTE Transcarotid System with flow reversal for neuroprotection. Via a longitudinal right medial neck incision, right common carotid artery was exposed and controlled. Left common femoral vein was used to insert venous component of ENROUTE sheath. Right common carotid was cannulated in retrograde fashion and ENROUTE sheath placed over the wire. Flow reversal initiated. Lesion crossed with wire and catheter combination, the lesion was pre-dilated with a 4 mm balloon and a 7 mm Shockwave balloon was used with favorable results. The sheath was advanced over the wire into aortic lumen and 11x39mm Gore VBX stent deployed and flared within aorta with 12 mm balloon.
DISCUSSION: Completion angiogram was notable for favorable lesion response, patent innominate, right common carotid and subclavian arteries. ENROUTE filter analyzed and debris found. Patient tolerated procedure well, was neurologically intact postoperatively and had palpable radial pulse and improved endurance in the right upper extremity with activities of daily living. This case illustrates the effectiveness and safety of hybrid approach utilizing shockwave intravascular lithotripsy in tandem with flow reversal system when treating aortic arch vessel lesions even with significant calcium burden. To our knowledge this is the first case in which shockwave and flow reversal neuroprotection was used for treating an innominate artery lesion.
Back to 2023 Abstracts