Case Report

Long-Term Patency of a Drug-Coated Balloon in the Treatment of Upper Extremity Peripheral Artery Disease

Syed M. Ahmed, MD, Morris Hospital, Morris, Illinois

Syed M. Ahmed, MD, Morris Hospital, Morris, Illinois

Atherosclerosis is a systemic disease of the large- and medium-sized arteries causing luminal narrowing (focal or diffuse) as a result of the accumulation of lipid and fibrous material between the intimal and medial layers of the vessel.1 Non-coronary atherosclerotic vascular disease is called peripheral arterial disease (PAD), affecting approximately a half-million people within the United States. Up to half have symptomatic atherosclerotic lower-extremity disease. The prevalence of atherosclerotic peripheral arterial disease of an upper extremity is less common than lower-extremity disease. Percutaneous transluminal angioplasty and stenting have been a mainstay for the treatment of lower-extremity PAD. Treatment of PAD with a drug-coated balloon is an emerging technique.2 Drug-eluting devices inhibit neointimal growth of vascular smooth muscle cells with the potential of preventing restenosis.3 In the case herein, a drug-eluting balloon is used for the treatment of upper extremity atherosclerotic PAD.

Case Report

A 62-year-old male with a history of type II diabetes and dyslipidemia initially came to our hospital with shortness of breath. He was diagnosed with non-ST segment elevation myocardial infarction (Type I). He underwent a surface transthoracic echocardiogram that showed severely reduced left ventricular systolic dysfunction with an estimated left ventricular ejection fraction of 30-35%. The patient underwent catheter-based coronary angiography, followed by percutaneous intervention of the left anterior descending (LAD) coronary artery and left circumflex (LCX). He later complained of dizziness and was referred to a neurologist to rule out a transient ischemic attack (TIA)/cerebrovascular accident (CVA). A magnetic resonance imaging (MRI) of the patient’s brain showed no evidence of acute infarct or intracranial abnormalities. Magnetic resonance angiography (MRA) of the neck revealed a 90% atherosclerotic stenosis in the proximal segment of the left subclavian artery with reversal of flow in the left vertebral artery, suggestive of left subclavian steal syndrome. The patient underwent catheter-based peripheral angiography that showed a severe proximal subclavian artery stenosis adjacent to the origin of the left vertebral artery (Figure 1). There was concern that a stent might jail the left vertebral artery. Therefore, it was decided to perform percutaneous transluminal angioplasty (PTA) and consider provisional stenting if PTA had an unsatisfactory result.

A 6 French (Fr) Judkins right (JR) 4 guide catheter was used to engage the left subclavian artery. After an intravenous heparin bolus, a Glide Advantage wire (Terumo) was used to cross the lesion. Subsequently, the JR-4 catheter and 6 Fr sheath were exchanged to a 7 Fr, 90 cm long Destination sheath (Terumo), as a 6 Fr sheath was not compatible with a large-size balloon. The long sheath was placed proximal to the lesion. The lesion was prepared by using a 6.0 x 40 mm EverCross non drug-coated balloon (Medtronic). A 7.0 x 40 mm Admiral drug-eluting balloon (Medtronic) was placed at the lesion and inflated to nominal to high pressure for 3 minutes. The balloon was deflated and pulled out from the sheath. Post-intervention angiography showed an excellent angiographic outcome with no residual stenosis (Figure 2). Two years after the procedure, the patient developed symptoms of vascular claudication (a non-healing ulcer of the lower extremity) requiring catheter-based angiography. At this time, repeat angiography of the upper extremity (performed due to new-onset symptoms of dizziness) showed a patent left subclavian artery (Figure 3). The patient’s dizziness improved after hydration and reducing the dose of his antihypertensive medicine.

Discussion

Angioplasty with a non drug-coated balloon causes fracture of atherosclerotic plaque and injury to adjacent endothelial cells and medial wall. This results in deposition of platelets, fibrin, and release of inflammatory markers, causing stimulation of mitosis and resulting in smooth cell hyperplasia in the intima of the vessel. Intimal hyperplasia results in a high restenosis rate at 12-month follow-up with the use of a non drug-coated balloon.4,5 Endovascular treatment of short (<10 cm), non-occlusive lesions with a drug-coated balloon shows improved patency and a reduction in target lesion revascularization.6,7 This case demonstrates the use of a drug-coated balloon in upper-extremity PAD is safe and has long patency. However, a large trial is needed to prove its efficacy. 

Disclosure: Dr. Ahmed reports no conflicts of interest regarding the content herein.

Dr. Syed Ahmed can be contacted at sahmed@morrishospital.org.

References
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