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 Innominate, Subclavian and Vertebrobasilar Arterial Disease

By Matthew L. White, MD and Joseph L. Mills, MD

Based on original curriculum outline prepared by: Ramon Berguer, MD, Michael DaValle, MD, Francis Robicsek, MD


Includes:

  • Stenotic and Embolic Innominate Artery Disease
  • Stenotic and Embolic Vertebral Artery Disease
  • Stenotic and Embolic Subclavian Artery Disease
  • Subclavian Steal Syndrome
  • Arteriopathies (Fibromuscular dysplasia, Takayasu’s Disease and Giant Cell Arteritis)
  • Trauma: Dissection, Aneurysm and Vertebral Arteriovenous Fistulae

JUNIOR LEVEL

I. Etiology, Pathophysiology and History

1. To describe the pathophysiologies of atherosclerosis, trauma, dissection, fibromuscular dysplasia, arteritis and radiation as they apply to the innominate, subclavian and vertebrobasilar arteries.
2. To be familiar with concomitant diseases and associated risk factors commonly associated with stenosis, occlusion, dissection, ulcerated atheroma, arteriovenous fistula and false aneurysm of these arteries.
3. To define the most appropriate diagnostic steps for the evaluation and treatment choice for these conditions.

II. Diagnosis

1. To define the symptoms and signs of brain ischemia in its various manifestations, localized and global, flow-related versus embolic, progressive and sudden.
2. To recognize the signs and symptoms of upper extremity ischemia.
3. To be familiar with the signs of ischemia of the brain or upper extremities elicited by provocative maneuvers.
4. To understand the differential diagnosis of conditions that may present with similar signs or symptoms.
III. Treatment

1. To understand the options for medical treatment (antiplatelet, anticoagulant, steroids, anti-inflammatory drugs).

SENIOR LEVEL

I. Etiology, Pathophysiology and History

1. To be able to understand and describe the abnormal and alternative flow patterns that may develop as a consequence of lesions of the innominate, subclavian and vertebrobasilar arteries.
2. To have familiarity with the most appropriate diagnostic methods available to assess end-organ effects in the brain and upper extremities of the lesions mentioned above.
3. To describe the natural history of these conditions and how this natural history is affected by treatment methods.

II. Diagnosis

1. To understand how noninvasive tests may detect or exclude the presence of lesions of the innominate, subclavian and vertebrobasilar arteries and when such tests suggest the need for CTA, MRA or formal arteriography.
2. To understand the anatomy of these arteries and their lesions as defined by arteriography, the timing of films and the best projections to display them.
3. To know the risks involved in arteriography relative to the contrast agents used and their amount, the approach used and the pharmacologic and technical maneuvers employed.
4. To recognize the value and limitations of CT and MRA/MRI imaging techniques in the diagnosis of these entities.

III. Treatment

1. To describe and understand the options for surgical repair, whether direct (endarterectomy, transposition, ligation), indirect (bypass, decompression), or endovascular (angioplasty, stenting, covered stents).
2. To understand the indications for combined versus staged treatment of multi-vessel disease, especially sequence and timing of interventions.
3. To describe the potential complications of each of the above treatments and their management.
4. To be familiar with the long-term results of the various treatment options.

References

1. Kieffer E, Sabatier J, Koskas F, Bahnini A. Atherosclerotic innominate artery occlusive disease: early and long-term results of surgical reconstruction. J Vasc Surg 21(2):326-37, 1995.
2. Owens LV, Tinsley EA Jr, Criado E, Burnham SJ, Keagy BA. Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks. J Vasc Surg 22(3):217 - 22, 1995.
3. Berguer R, Kieffer E: Surgery of the Arteries to the Head, Springer-Verlag New York Inc., New York , 1992.
4. Hallett JW, Mills JL, Earnshaw JJ, Reekers JA, Rooke TW. Chapter 16. Rhodes JM, Cherry KJ, Dake MD. “Upper Extremity Ischemia: Aortic Arch” (293-308) and Chapter 38. Kieffer, E. “Surgery for Vertebrobasilar Insufficiency” (647-664). In: Comprehensive Vascular and Endovascular Surgery. 2nd Edition. Mosby Elsevier. Philadelphia, 2009.

Posted September 2010