From the Guidelines
Treatment for severe left subclavian artery stenosis typically involves revascularization, with both endovascular intervention and surgical bypass being considered as viable options. The choice between these approaches depends on various factors, including the patient's overall health, the severity and location of the stenosis, and the presence of any contraindications to either method 1.
Endovascular Intervention
Endovascular intervention with angioplasty and stenting is often considered the first-line approach for treating severe left subclavian artery stenosis. This procedure involves accessing the arterial system, usually through the femoral artery, navigating to the stenotic area, dilating the narrowed segment with a balloon, and placing a stent to maintain vessel patency. Prior to intervention, patients should receive antiplatelet therapy with aspirin and clopidogrel. Following stent placement, dual antiplatelet therapy should continue for at least 1-3 months, followed by lifelong aspirin therapy 1.
Surgical Bypass
For patients with contraindications to endovascular treatment or complex lesions, surgical bypass may be necessary. Surgical bypass typically involves carotid-subclavian or subclavian-subclavian bypass and is associated with low morbidity and mortality and excellent long-term patency 1.
Medical Management
Medical management alone is generally insufficient for severe stenosis but should include aggressive risk factor modification, such as smoking cessation, blood pressure control, lipid management with high-intensity statins, and diabetes control if applicable. Intervention is particularly important when patients exhibit symptoms of subclavian steal syndrome, arm claudication, vertebrobasilar insufficiency, or when the left internal mammary artery is needed for coronary bypass grafting 1.
Recent Guidelines
Recent guidelines, such as the 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, recommend considering revascularization in symptomatic patients with subclavian artery stenosis/occlusion, and discussing both revascularization options (stenting or surgery) on a case-by-case basis according to the lesion characteristics and patient’s risk 1.
Key Considerations
- Symptomatic Patients: Revascularization should be considered in symptomatic patients with subclavian artery stenosis/occlusion.
- Asymptomatic Patients: Revascularization may be considered in asymptomatic patients with specific conditions, such as proximal stenosis in patients undergoing or having undergone CABG using the ipsilateral internal mammary artery, or in the presence of an ipsilateral arteriovenous fistula for dialysis.
- Risk Factor Modification: Aggressive risk factor modification is crucial in all patients with subclavian artery stenosis.
In summary, the treatment approach for severe left subclavian artery stenosis should be individualized, considering the patient's specific clinical scenario, the severity of the stenosis, and the potential risks and benefits of each treatment option, with the goal of improving morbidity, mortality, and quality of life outcomes.
From the Research
Treatment Options for Severe Left Subclavian Artery Stenosis
- Medical therapy is often the initial treatment approach for asymptomatic subclavian artery disease, as stated in 2.
- For symptomatic patients, combination therapy involving antiplatelet drugs and either bypass surgery or percutaneous transluminal angioplasty (PTA) with or without stent implantation may be considered, as suggested by 3.
- Stenting of the left subclavian artery has been shown to be a safe and effective method for treating coronary-subclavian steal syndrome, with a high level of technical and clinical success, as reported in 4.
Interventional Treatment Approaches
- Percutaneous transluminal angioplasty (PTA) has been compared to conservative treatment in terms of long-term hemodynamic and symptomatic outcome, with PTA showing a 60% risk reduction for hemodynamic subclavian stenosis, as found in 5.
- Bifurcation T-stenting using a self-expandable bare metal and a coronary drug-eluting stent has been used to treat complex left subclavian artery stenosis involving the vertebral artery, as described in 6.
Considerations for Treatment
- The decision to treat severe left subclavian artery stenosis should be based on the presence of symptoms, such as vertebrobasilar insufficiency, critical ischemia, or peripheral emboli, as noted in 5.
- Combination therapy may be associated with less cardiovascular adverse events and higher survival rates compared to antiplatelet drug therapy alone, as suggested by 3.