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Abstract
Introduction (Chronic occlusion of brachiocephalic trunk (BCT) often present with TIA and stroke in posterior territory due to steal syndrome. Endovascular recanalistion ist complex and require multiple catheters and accesses 1. We present a case of complex recanalisation of a BCT chronic in-stent occlusion.
Case Description (A 83-yo woman presented with exacerbating dizziness and arms blood pressure difference. A BCT-stent from 2004 was chronically occluded and followed up in a different hospital. Angiography confirmed severe steal syndrome to right subclavian and common carotid artery (CCA) (figure 1a). Endovascular recanalisation through right brachial artery access with a .035’ guide wire and a drug-coated balloon ’DCB’-PTA (Ranger 8x40mm; Hemoteq) was performed with immediate angiographic improvement of the steal syndrome (figure 1b). A concomitant high-grade proxiamal right CCA stenosis was treated with stent-PTA (CGuard 7x40mm; InspireMD) through femoral access. A post-interventional right arm ischemia improved with conservative treatment. The patient still suffered from occasional dizziness. Ultrasound and CTA 3-months follow-up showed a recurrent severe BCT in-stent stenosis with a calcified plaque. Repeat angiography at 4-months confirmed recurrent steal syndrome and severe in-stent stenosis. Therefore, in-stent stent-PTA (Omnilink 7x19 mm; Abbott) (figure 2a) and DCB-PTA (Lutonix 5x40mm; Bard) of a right CCA severe in-stent stenosis was performed (figure 2a). Steal syndrome was resolved. The patient reported resolution of dizziness.
Results Endovascular recanalisation of chronic brachiocephalic trunk in-stent occlusion is complex and requires multiple accesses, however it is safe and feasible. After careful consideration it should be considered in symptomatic patients.