Introduction Co-existing stenoses of both the subclavian artery(SCA) and vertebral artery(VA) is uncommon and poses a specific challenge in treatment when atherosclerotic plaque involving VA ostium overlies area of SCA stenosis, and may require bifurcation techniques to preserve flow through VA during SCA revascularization procedures. Common in coronary arteries, bifurcation techniques have been rarely described in supra-aortic vessel angioplasty procedures. We describe a case of symptomatic severe stenoses treated with above technique after failed medical therapy.

Materials and Methods Pubmed search of case reports/series.

Results A 68 year-old-female presented with fluctuating aphasia and right facial palsy (NIHSS 2). MRI showed embolic strokes in the L-MCA territory. CTA showed proximal L-CCA occlusion with reconstitution in distal portion via L-ECA, chronically occluded R-SCA and R-VA origin, remainder as below. Patient was started on IV heparin infusion plus aspirin. Symptoms stabilized however worsened days later when she became anemic with hypotension from groin hematoma after A-line removal. Patient was switched to DAPT and taken for emergent DSA which showed overlapping severe(80%) stenosis of L-VA ostium (ending in PICA) and proximal L-SCA(90%) stenosis. L-VA muscular branches reconstituted left occipital artery which reconstituted distal L-CCA/L-ICA. Inferior thyroid artery anastomoses with superior thyroid artery reconstituting L-ECA/L-CCA/L-ICA. Additionally there’s distal BCTA/R-CCA origin severe(85%) stenosis. R-ICA supplied L-ICA and posterior circulation via ACOM and R-PCOM. An exchange-length-glidewire was placed in cervical R-ICA, and diagnostic catheter and groin sheath were exchanged out for 7Fx80cm guide catheter. A 5mm SpiderFX EPD was placed in cervical R-ICA. BCTA stenosis angioplasty done with 4x30mm, then 7x20mm Viatrac balloons. Filtered was retrieved, DSA showed residual(50%) stenosis and improved cross-filling of L-ICA and posterior circulation via R-ICA. Guide catheter was withdrawn and advanced to proximal L-SCA over glidewire and diagnostic catheter. A 4mm SpiderFX EPD was deployed in distal L-V2 segment and 0.014’microwire was used to cross L-SCA stenosis. Coyote 2x20mm balloon was positioned in L-VA ostium with Viatrac 4x30mm balloon across L-SCA stenosis in a kissing fashion at their proximal ends. Balloons were simultaneously inflated to nominal pressures. We repeated same process with Sterling 3x20mm balloon in L-VA, Viatrac 5x20mm balloon in L-SCA. EPD was retrieved and DSA showed improvement in flow with residual(25%) stenosis in L-VA and residual(50%) stenosis in L-SCA. Antegrade flow was seen in R-VA from L-VA/L-SCA likely via median-crossing muscular branches. Patient was monitored in ICU and discharged later with NIHSS 1. Due to possibility of jailing L-VA and resultant occlusion after SCA stent placement, PTA alone was used for SCA treatment. Given small diameter VA and evidence of high restenosis rates after stenting small arteries, we limited to PTA only for L-VA and reserved stenting for severe residual/recurrent stenosis.

Conclusions Single balloon inflation in one artery at a bifurcation could potentially result in compression of the contralateral artery leading to occlusion and risk of embolization. To minimize these potential complications and snow-plow effect, concurrent inflation of bilateral balloons is employed. Simultaneous kissing angioplasty is a minimally invasive treatment alternative in challenging cases of overlapping VA and SCA stenoses.

Disclosures M. Ismail: None. S. Bhagavan: None. A. Razak: None. O. Qahwash: None.