A Broken Railway: A Subclavian Arterial Stent Fracture.

A 63 year-old male moving company worker, presented with left arm pain when lifting some luggage for 3 months. His blood pressure revealed 84/53 and 134/72 mmHg in left and right arm each. Computed tomographic angiography (CTA) showed a total occlusion of the left proximal subclavian artery (Figure 1A). Percutaneous transluminal angioplasty (PTA) with a balloon expandable Express LD® stent (7×57 mm; Boston Scientific, Marlborough, MA, USA) was performed successfully, however 11 days postoperatively his symptom reoccurred and stent fracture was suspected in routine chest X-ray, confirmed by CTA and causing a significant stenosis (Figure 1B-E). This lesion was re-stented with self-expandable Absolute Pro® stent (7×40 mm; Abbott Laboratories, Abbott Park, IL, USA) (Supplementary Videos 1, 2, 3, 4). Six months post-rePTA treatment, there were no symptom and no definite stent fracture on chest X-ray (Figure 1F and G). The systolic blood pressure showed 120–130 mmHg in both arms.

Figure 1

(A) CTA showed a total occlusion of the left proximal subclavian artery (arrowheads). (B, C) CTA showed a stent fracture of left subclavian artery (arrowheads). (D) Chest X-ray on the day of PTA showed continuity of left subclavian stent (arrowheads). (E) Chest X-ray 11th day after PTA showed a stent fracture of left subclavian artery at mid portion (arrowheads). (F, G) Chest X-ray on the day of and 6 months after re-PTA showed repaired continuity of left subclavian stent (arrowheads).

CTA = computed tomographic angiography; PTA = percutaneous transluminal angioplasty.

We used self expandable nitinol stent in stent-fractured lesion, which is more flexible than balloon expandable stainless steel stent. Both stents can be used in subclavian artery lesion.1) Although being unclear for the cause of these events, a recent study revealed the presence of long lesions and heavy calcification to be significant independent predictors.2) The principal mechanism can be the mechanical fatigue of stent from frequent wide-angled shoulder movement or repeated strong pulling force of upper extremities as well as overexpansion.3) Different blood pressure in both arms, upper extremities pain or suspicious stent finding on chest X-ray after PTA can help us identify the subclavian arterial stent fracture.

Written informed consent was obtained from the patient.