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Complex Stenting (T-Stenting) of Left Subclavian Artery & Vertebral Artery Stenosis
- Operator: Seung-Whan Lee. MD
Clinical Information

- Relevant clinical history and physical exam:
The patient was 74 years old man. He has been suffered from long-term (about 30 years) diabetes. About 10 years ago, he received primary coronary intervention due to primary STEMI. Recently, he have been complained minimal effort-related chest discomfort and evaluated the coronary heart disease. The diagnostic coronary angiography showed three vessel disease with neo-intimal hyperplasia in previous stenting site. So, we recommended the coronary bypass graft surgery. And during the preoperation work-up, the MR angiography showed focal severe stenosis in Rt. subclavian artery, Rt. carotid artery bulb area and left vertebral artery ostium. We decided to staged endovascular revascularization due to multiple lesions for perioperative surgical risk reduction. We deployed SMART-CONTROL self expandable sent (7.0 x 30 mm) in Rt. carotid bulb area and Express self-expandable stent in Rt.subclavian artery stenosis, 2 days ago, uneventfully. We planned Lt.vertebral artery ostial stenosis intervention.

- Relevant test results prior to catheterization:
The brain MR with angiography showed the severe stenosis in left vertebral artery ostium and left subclavian artery. (Figure 1, Figure 2)

- Relevant angiography findings:
The pre-intervention angiography showed severe restenosis of left vertebral artery ostium with significant stenosis in left subclavian artery just proximal to VA origin.(Figure 3)

Interventional Management
- Procedural step:
After Rt. femoral puncture, 7Fr sheath was inserted. The 5 Fr head-hunter catheter using 0.032 inch Terumo wire was engaged into left subclavian artery. And then was exchanged to 7Fr Shuttle. The 0.014 inch coronary floppy guide wire was inserted into left VA artery. The VA ostial stenotic lesion was predilated with coronary Quantum balloon (3.0 x 12 mm) upto nominal pressure. (Figure 4) We deployed the Genesis stent 5.0 x 15 mm. (Figure 5) At stepwise intervention, We deployed Genesis stent 9.0 x 39 mm at Lt.subclavian stenotic lesion, resulting T-stenting bifurcation technique with previous stent. (Figure 6, Figure 7, Figure 8) The post-stent balloon dilatation with Powerflex 9.0 x 20 mm was done at Lt. subclavian artery stenting lesion. The 0.014 inch coronary guide-wire was re-inserted into VA and the high pressure ballooning with non-compliant balloon was done. (Figure 9) The final angiogram showed successful stenting at Lt.subclavian artery and Lt.VA ostial lesion without any procedural related neurologic complications. (Figure 10, Figure 11)
Good results. Few questions: 1. Were there any neurological symptoms requiring left vertebral artery stenting? 2. In your experience what is the incidence of instent restenosis after vertebral stent?
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