Percutaneous transluminal angioplasty and stenting for innominate artery pre-occlusive stenosis with subclavian steal syndrome – case report and current challenges

Introduction. Atherosclerotic occlusive disease of the innominate artery (IA) represents a rare entity, comprising less than 2% of all extracranial causes of altered cerebral blood flow. This type of lesion is associated with adaptative hemodynamic changes increasing the risk of developing both cerebral and upper extremity ischaemia. Subclavian steal syndrome is a serious complication that may occur with occlusive lesions of the innominate artery and may represent an indication for revascularization. Case presentation. In the current paper we present the case of a patient who was admitted in our clinic for further investigations regarding episodes of dizziness and a difference of 30mmHg in the systolic blood pressure between his arms. On duplex ultrasonography scanning, an IA stenosis suspicion was raised, with associated retrograde flow through the right vertebral artery (VA) at light efforts of the right upper extremity. An angiographic evaluation confirmed the sub-occlusive lesion and reversed flow through the right VA. A decision was reached to undertake percutaneous transluminal angioplasty and stenting. There was no report of periprocedural complications, the intervention has been considered successful with no restenosis and no neurologic symptoms at 9 months follow-up. Discussion. Until recently, surgical treatment was the only option in the management of atherosclerotic disease of the IA, a procedure with high complication, morbidity and mortality rate. Therefore, endovascular treatment gained more ground and is considered today as the first line of treatment for this type of lesion. Conclusion. PTA and stenting of the IA still remains challenging mainly due to complex anatomy and the rarity of this pathology and we must keep in mind that the decision for the revascularization technique is personalized. This present case brings new evidence that percutaneous transluminal angioplasty is a safe and efficient method to manage an atherosclerotic lesion of the brachiocephalic artery