The first reports of surgical treatment of aortic arch branches were published in 1950s (14,
15).
Although the functional results of these procedures were satisfactory,
the operative mortality rate was exceedingly high (14).
Because of the risks of transthoracic procedures,
extra-anatomic (carotid-subclavian) bypass grafting was introduced in the late 1960s (16). Their good results and low mortality were confirmed by later studies (17,
18).
PTA of the aortic arch branches was introduced in 1980 by Mathias et al and Bachman and Kim,
and has subsequently evolved as an effective and safe treatment modality for lesions of the subclavian and innominate arteries (4,
19).
Percutaneous therapy for occlusive arterial disease may have several advantages over standard surgical therapy,
including its minimally invasive nature,
fewer complications,
avoidance of general anesthesia,
greater patient acceptance,
and lower cost-per-unit treatment; in general,
however,
these procedures are not as durable as their surgical alternatives (7).
Technical success of endovascular treatment for stenoses in most series ranges between 91% and 100% (6,
7,
11,
20).
For total occlusions reported technical success is rather lower ranging from 25% (21) to 83% (22).
No perioperative deaths were reported,
and only one major stroke was reported by Henry (20).
Minor strokes (TIAs included) rate ranges from 0,9 to 1,4% (3,
5-7,
10,
11,
20-23).
Major complications which include access site hematomas,
distal embolization,
and arterial thrombosis range from 0% to 10% (6,
7,
20,
22).
These complication rates,
especially perioperative deaths and stroke rates,
are exceedingly in favor of endovascular treatment compared with surgery (2).
Patency is comparable with surgery,
although randomized studies have not been published yet (2).
Short-term patency after endovascular treatment is excellent,
several studies reported 91-92% patency 2 years after endovascular treatment (6,
11,
23).
Long-term patency is inferior compared to surgery (2).
Schillinger reported 4-year patency rates of 68% after PTA,
and 59% after stenting (24).
In the study by Bates 5 years patency after stent placement was 72% (23).
Seventy-nine percent patency 4 years after PTA was published by Hebrang (10).
For stenotic lesions,
either strategy is reasonable,
as there is no definite difference in outcomes between PTA and stents.
However,
for occlusions the results of primary stenting are better than PTA alone (25).
Przewlocki et al have identified 3 independent restenosis risk factors: the implantation of more than one stent,
low stent diameter,
and difference in systolic blood pressure between the arms after the procedure (8).
Stent diameter should be 1–2 mm larger than the index artery (25).
This could explain both of 2 in-stent restenoses in our study.
Diameters of implanted stents were the same as of occluded arteries.
Simptomatic restenoses or reocclusions are indications for reintervention.
Reported series of patients having reintervention show excellent results of secondary patency (91,7-98% patency in mean time follow-up from 18 to 117 months) (6,
8,
9,
11).
Varcoe et al reported case report of successful endovascular treatment of recurrent in-stent restenosis with paclitaxel-coated balloon (PCB) (26).
Both of in-stent restenoses in our study were also treated with PCBs.
Reporting standards for interventions of aortic arch branches were adapted from reporting standards for lower extremity (13) by Sullivan et al (7). Both clinical and hemodynamic success must have been maintained for the intervention to be deemed patent.
Angiography is the only reliable method to assess anatomic patency of interventions performed in these vessels.
Other,
less invasive methods (ultrasound,
CTA and MRA),
are insufficient to make an accurate estimate of stenosis (7).
The results,
both initial and long-term,
of endovascular treatment for lesions of subclavian and innominate arteries in our study are comparable with published data.
Also the safety of procedures is acceptable and within ranges reported in published data.
Patency after treating short stenoses was better than in the case of longer lesions.
Surgery is only indicated if endovascular treatment fails.
Restenosis and reocclussion are also indications for endovascular treatment.
Recent introduction of PCBs is promising,
but further studies have to evaluate their effect.