Author + information
- Dattatreya PV. Rao1
Patient initials or identifier number
Relevant clinical history and physical exam
History and presentation: 19 years old lady presented with recurrent history of syncope which was more during standing, working and during use of “hands”. There was a recent history of frontal lobe infarct 3 months ago. She was diagnosed as a case of takayasu arteritis and was on steroids and methotrexate as she was in active phase of the disease.
On examination, there were no bilateral carotids and left radial pulse and a feeble radial pulse on right side.
Her ESR was 32 and CRP negative.
Relevant test results prior to catheterization
Diffusely diseased B/L carotids occluded subclavian artery on left side and critical stenosis of the innominate artery. Blood supply of the whole brain dependent upon right vertebral artery. On pepeated working, she used to have subclavian steal, which makes her fall Aorta normal. Renal arteries were patent.
Relevant catheterization findings
The right vertebral artery is the sole blood supply to brain. Other neck vessels occluded. Tight stenosis of innominate artery. Abdominal aorta was normal. Coronaries were normal.
Challenges for an intervention of single surviving brain feeder:
1. How well she tolerate procedure? Any Stroke on the table?
2. Restenosis rate?
3. Medications to be given on follow up?
Approach: Right femoral artery:
Guide: Judkin right with 3.5 curve.
Lesion crossed with 0.014” Cougar PTCA wire.
It then pre-dilated with 4 x 10 mm coronary balloon and stented with 6 x 15 Balloon expandable cobalt chromium stent.Post stent angio and late phase injection reveal retrograde filling of the Left subclavian artery. Residual obstruction is post dilated with 6 x 10 mm balloon. Lesion of the left subcalvian artery planned for staged intervention. The patient tolerated the procedure well. There were no complications.
After 3 months patient presented with left arm claudication and intermittent syncopal attacks. At this stage we were sure that it is from totally occluded left subclavian artery causing a subclavian steal, compromising cerebral circulation and planned for second intervention.
Second intervention: Access was left radial artery. With the help of 6F JR catheter which was placed at the distal end of occluded subclavian artery, a 0.014“PTCA wire (BMW,Cross it,Pilot 150) was used to cross the lesion, but could not be succeeded. Later a 0.035” straight tip terumo wire was used to cross initially with soft tip, later with hard end which crossed the lesion easily. Later, terumo wire was snared from femoral artery and a loop was established. 6 X 40 mm balloon was used to dilate the lesion at 16 atm. Later stented with 7 X 40 mm omnilink ELITE stent deployed at 12 atm. End result was excellent with no residual stenosis.
She was discharged with minimal dose of steroids.
During first month of follow up, patent was totally asymptomatic and further episodes if syncope. Follow p ESR was 12 and CRP was negative.
• This case shows varied presentation of Takayasu’s arteritis. The disease is disabling especially affecting young
• Endovascular therapy is a simple yet effective way of treating these patients
• Patients need multi–disciplinary modalities to demonstrate lesions
• Disease activity to monitored, if active to be treated with steroids ± methotrexate to prevent re-stenosis