Drug-Coated Balloon Angioplasty for Thoracic Great Vessel Stenosis Due to Takayasu Arteritis With 1-Year Follow-up

DCB Angioplasty to Stenosed Thoracic Great Vessels

Twenty days later her ESR had normalized to 5 mm/h so she did not have active disease and could undergo intervention. Angiogram was performed showing stenosis of the innominate artery at 80% and the right common carotid artery showing 95% narrowing, left common carotid with 95%/subtotal occlusion, total occlusion of the left subclavian artery, and 90% narrowing of the left vertebral artery (Figure 2). Prior to intervention, the case was reviewed with multiple in-house and national consultants to discuss surgical versus percutaneous treatment options, but there was no consensus on best options because of the lack of data. Therefore, it was decided to attempt intervention with DCB angioplasty. Balloon and stent sizes were based on the carotid size, using a 1:1 sizing estimate. Angioplasty with a 7 mm × 60 mm IN.PACT Admiral DCB (Medtronic, Minneapolis, Minnesota) of the innominate artery was performed causing the patient to have momentary loss of consciousness with balloon inflations. Two further dilations of the innominate were performed with narrowing reduced to less than 30%. A SpiderFX distal protection device (Medtronic) was placed in the right internal carotid artery and the right common carotid artery was angioplastied with a 6 mm × 40 mm IN.PACT Admiral DCB, but a segment was poorly dilatable at 34 atm even after use of a cutting balloon, so 2 iCAST-covered stents (Atrium Medical Corp., Hudson, New Hampshire), 5 mm × 22 mm and 7 mm × 16 mm, were deployed with narrowing reduced to less than 40%. The use of covered stents was used to try to decrease restenosis because no large drug-eluting balloon–expandable stents were available in the United States and self-expanding drug-eluting stents were not chosen because of the lack of hoop strength. Her carotid stenosis was fibrotic, such that a balloon-expandable stent would be more likely to achieve larger lumen patency. Because of contrast limitations, further interventions were performed the following day. On the second day of intervention, a SpiderFX distal protection device was placed into the left internal carotid artery and the lesion was angioplastied with a 4 mm × 60 mm Sterling balloon (Boston Scientific Corp., Marlborough, Massachusetts) followed by a 5 mm × 60 mm IN.PACT Admiral DCB with narrowing reduced to 30%. After using multiple wires, catheters, and balloons, the occluded left subclavian artery was angioplastied with a 5 mm × 150 mm Lutonix DCB (Bard Peripheral Vascular Inc., Tempe, Arizona) with narrowing reduced to 25%. Angiography did not reveal any high-grade lesions in the thoracic aorta, abdominal aorta, celiac, or superior mesenteric arteries. She was discharged on clopidogrel, continued on mycophenolate mofetil and steroids, and started on metoprolol for persistent tachycardia.

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Figure 2.

Angiogram of thoracic great arteries prior to intervention. Stenoses were estimated at 80% for the innominate, 95% for the right common carotid, 95% for the left common carotid, total occlusion of the left subclavian artery, and 90% narrowing of the left vertebral artery.

Follow-up and Subsequent Interventions

By her 3-month follow-up, she noticed a return of her neck pain and tachycardia. Arterial duplex ultrasound showed recurrent innominate, bilateral carotid, and left subclavian artery stenosis. The decision was made to once again undergo intervention. The left common carotid had restenosis to 75% so was angioplastied with a 7 mm × 80 mm IN.PACT Admiral DCB, but still had intermediate stenosis so was further dilated with a cutting balloon which dissected the artery, so a 6 mm × 59 mm iCAST-covered stent was placed. The innominate artery had 50% stent restenosis, so a 7 mm × 22 mm iCAST-covered stent was deployed in the previous stent. The left subclavian had 60% restenosis so was angioplastied with a 6 mm × 150 mm IN.PACT Admiral DCB.

Two months after her second intervention, and 5 months after her index interventions, she developed right arm claudication. Angiogram showed that she had new stenosis of her right subclavian artery which was dilated with a 7 mm × 40 mm Lutonix DCB. The angiogram also showed patency of all the great thoracic vessels and no restenosis of previous lesions. At 9 months after her index interventions, arterial duplex ultrasound and CT angiogram of her chest did not show high-grade stenosis of her aortic branches.

At 1-year follow-up, she had increased velocities noted in the stents in both the right and left common carotid arteries on arterial duplex ultrasound. Aortic arch angiography showed persistent high-grade stenosis of the left vertebral artery for which intervention was previously deferred. Initially, a 4 mm × 32 mm Promus ELITE stent (Boston Scientific Corp.) was deployed in the left subclavian, but this caused plaque shift and jailing of the subclavian, so a 6 mm × 14 mm Express SD stent (Boston Scientific Corp.) was placed in the left subclavian at the level of the left vertebral artery. On intravascular ultrasound, there was a flap extending into the left subclavian artery below the origin of the left vertebral artery and a probable dissection with 2 lumens that likely developed as a result of prior intervention. Therefore, a second 4 mm × 20 mm Promus ELITE stent was placed in the left vertebral artery extending down into the left subclavian flap. The bilateral carotid arteries had stent restenosis and the right subclavian artery had intermediate stenosis, so the case was reviewed with multiple in-house and national consultants who recommended further carotid stenting rather than surgical intervention. Two weeks later, a 7 mm × 16 mm Express LD (Boston Scientific Corp.) was deployed in the right ostial subclavian artery. An iCAST-covered stent was deployed stent-in-stent in both the right (6 mm × 38 mm) and left (7 mm × 38 mm) common carotid arteries for stent-restenosis. Interestingly, the right common carotid was poorly dilatable during the initial intervention the previous year, but with 20 atm of pressure, the narrowing was reduced to less than 20%.