Carotid angioplasty is a treatment for carotid artery disease – a procedure performed on carotid arteries when they become clogged or narrowed by an atherosclerotic plaque. The procedure involves the placement of an antiembolic protection filter past the narrowing, followed by the placement of a nitinol-stent at the level of the narrowing. The stent maintains the artery open and prevents it from narrowing again. Carotid angioplasty is an alternative to open surgery, being used when the traditional surgical procedures are not feasible or pose a high risk.
Subclavian arteries (there are two on each side of the neck) are branches of the aorta. Subclavian artery stenosis can be a cause of significant morbidity as it can lead to ischemia (due to insufficient blood supply in the tissues) affecting the upper extremities, brain and in some cases the heart.
What are the causes of stenosis?
Atherosclerosis (fatty deposits in the walls of blood vessels) is the most common cause of this condition. The risk factors associated with atherosclerosis are hypertension, smoking, obesity, dislipidemia, diabetes.
Other etiologies include arteritis (inflammation of the artery walls, i.e. Takayasu arteritis, giant cell arteritis), inflammation due to radiation exposure, compression syndromes, fibromuscular dysplasia, and neurofibromatosis.
Frequently, patients with subclavian artery stenosis have concomitent lesions of other vessels (coronary arteries – the heart vessels, carotid arteries – the main vessels of the neck, the arteries of the legs), so the patients affected with this disease are at increased risk of developing symptomatic coronary artery disease (angina – chest pain, or heart attack) and cerebrovascular events (eg. stroke).
The left subclavian artery is more likely to be affected (3-4 times more frequently), close to its origin from the aorta.
If there is an isolated stenosis, the symptoms may lack due to the collaterals (new vessels that open and facilitate blood supply to the affected areas).
The symptoms include muscle fatigue, arm pain (claudication), rest pain and finger necrosis (blocking the blood supply of the fingers caused by pieces of the atherosclerosis plaque), bleeding in the nails.
Neurologic symptoms may occur (due to coronary-subclavian “steal”, the blood is redirected from normal vessels that originate in the subclavian artery to the affected area): visual disturbances, syncope (loss of consciousness), ataxia, vertigo, dysarthria (difficulty in speaking), ataxia (inability to maintain balance), vertigo (dizziness) and facial sensory deficits. In patients with internal mammary artery (IMA) grafts as a result of coronary artery bypass graft (CABG) surgery, the symptoms of ischemic heart disease may be recurrent.
The indications for the interventional treatment are:
• Symptomatic ischemia
• Subclavian steal syndrome
• Important claudication of the arm
• In order to preserve the blood flow in the mammary artery or before the coronary artery bypass intervention using the mammary artery
• In case of ischemia after coronary artery bypass grafting (coronary-subclavian steal syndrome)
• In dialysed patients in order to preserve the dialysis catheter or in patients with axillary graft
• The “blue fingers” syndrome (finger necrosis caused by particles)
• Inability to measure the blood pressure
• Progressive stenosis or thrombi that can migrate in the cerebral circulation
• Asymptomatic patients have the indications for interventional treatment of subclavian artery stenosis if they are undergoing other cardiovascular revascularization procedures to preserve the normal blood flow to the brain or to increase it (when injuries of other vessels above the aortic arch are associated).
addBefore procedure - Preparation
A preoperative consultation is necessary to establish if the stenosis is suitable for the surgical or interventional treatment. The imagistic investigations aforementioned (artery Doppler, angiography, CT / angioCT, MRI / angioMRI) are very useful.
Before the procedure, the interventional cardiologist should be informed in case of history of allergy or in case of the suspicion of pregnancy. You must mention any medicines you might take (especially antiagregants – aspirin, plavix, or anticoagulants – Sintrom) or associated disorders (diabetes mellitus, renal disease)
Blood tests are performed to check the blood coagulation, hemoglobin level, renal function and if any pathology is associated, additional tests may be required.
Admission in hospital takes place the day before the procedure. In the morning of the procedure, the patient must remain fasting (not consuming food or liquids). Before the procedure, the patient will have to shave the inguinal area bilateral. The patient will receive a consent form that he have to read and sign.
addAfter procedure - Recovery time
Due to the noninvasive nature of the procedure, normally the postprocedure recovery is rapid.
After the procedure you will be kept under observation in the intensive care unit and later in your room. Bed rest for 12-24 hours is needed (avoid bending the leg to prevent complications at the puncture site). Most patients can leave the hospital after 1 day and resume their normal activity (avoid exercise for a period of time is recommended). You will receive recommendations regarding your recovery and the treatment to be followed post procedure.
Once at home the patient has to be careful in case that fever or chills, changes at the site of puncture (bleeding, haematoma – a collection of blood;! A little bruising may be normal), or any changes of the leg (changes of color, temperature or sensitivity) and neurological manifestations occur.
Is it painful?
The procedure involves general anesthesia, so the patient will not feel anything; after the intervention, medicines for pain are administered as needed (a little discomfort related to the incision is possible).
How long does it take?
The procedure time usually ranges between 1-2 hours; the procedure is performed in the cardiac catheterization laboratory.
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