B-06: Angioplasty - Arterial, Brachiocephalic
  • Indications
    • Symptomatic chronic brachiocephalic stenosis or occlusion (i.e., subclavian steal syndrome)
  • Contraindications
    • Contrast allergy (premedicate)
    • Uncorrected coagulopathy
  • Patient Evaluation
    • Patient's ability to cooperate, lie flat, hold still
    • Evaluate for combined femoral and axillary/brachial access
  • Preprocedure Orders
  • Tools
    • Vascular sheath (size appropriate to balloon catheter)
    • Femoral approach:
      • Bentson, Glide, and 260cm Rosen w/ H1 or JB1 catheter to cross lesion
      • Flex-T or Micro-Vena .018" w/ Tohey-Borst
    • Axillary approach:
      • Glide wire, 145cm Rosen, straight Glidecath to cross lesion (axillary)
      • Pigtail or H1/JB1 for control injections from arch
    • Heparin, verapamil, nitroglycerin for intraarterial injection
    • Angioplasty balloon sized to vessel diameter
  • Entry site
    • Femoral for carotid, left subclavian or distal stenoses
    • Combined femoral and axillary for most innominate stenoses
    • Combined femoral and axillary proximal left subclavian occlusions and high grade stenoses
  • Technique
    • Femoral approach: Cross stenosis w/ H1 or JB1 catheter and Bentson wire (Glide wire if Bentson fails), give IA meds, Rosen wire for exchange, position balloon, dilate (usually 6-12atm for 30-60 sec.), exchange for .018" wire, position balloon proximal to lesion, check result by injection through Tohey-Borst adapter.
    • Combined approach: Position diagnostic catheter (femoral) in arch. Cross lesion w/ Glidecath and Rosen or Glide wire. Give IA meds. Introduce balloon from axillary approach over Rosen. Position balloon and dilate. Withdraw balloon into subclavian and check result by injection through aortic catheter.
  • Post-procedure Note
    • Note angioplasty results, changes in distal pulses, and arterial pressure measurements if obtained
  • Post-procedure Orders
    • Additions to routine axillary or femoral post arteriography orders
      1. Heparin 2000 U SQ. q 6 hours x 48 hours - begin at [give time]
      2. ASA 1 tab (5 gr.) PO qd x life - begin today (x 6 months if angioplasty for FMH)
      3. Check and record upper extremity pulses w/ VS
      4. Neuro checks w/ VS to include orientation and grip strength

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