Endovascular techniques for supra-aortic trunk intervention.

Endovascular techniques have gradually become the preferred treatment modality for occlusive disease of the supra-aortic trunks (SAT). Stenotic lesions are particularly amenable to catheter-based therapy. Standard cervical bypasses or intrathoracic reconstruction is now generally reserved for cases of extensive, multivessel involvement or after failure of previous endovascular procedures. Angiographic assessment of aortic arch anatomy and equipment and technical choices for arch branch catheterization constitute the foundations. The left subclavian artery is most frequently diseased; interventional options revolve around antegrade and retrograde techniques. Preservation of the left vertebral artery-and at times of the internal mammary-is an important issue. Treatment of lesions in the proximal common carotid arteries tends to be straightforward when dealing with focal stenoses. Embolic protection should be used whenever feasible and reasonable. The innominate is often the most challenging SAT vessel because of its large diameter and short length, as well as the fact that it bifurcates into the right subclavian and common carotid arteries. Right subclavian artery intervention tends to be more difficult than its left-side counterpart, which is related to fluoroscopic visualization and the tendency for stenoses to develop in the very short segment between its origin and the take-off of the right vertebral artery. Supra-aortic trunk intervention has become more commonplace at present, but it is frequently difficult and carries significant potential for failure and mishap. These risks can be minimized through a complete understanding of the full spectrum of technical and catheter choices that are available to the interventionist.