Can Doppler Flow Parameters of Carotid Stenosis Predict the Occurrence of New Ischemic Brain Lesions Detected by Diffusion-Weighted MR Imaging after Filter-Protected Internal Carotid Artery Stenting?

BACKGROUND AND PURPOSE:Carotid angioplasty and stent placement are increasingly being used for the treatment of symptomatic and asymptomatic carotid artery disease. Carotid angioplasty and stent placement carry an inherent risk of distal cerebral embolization, precipitating new brain ischemic lesions and neurologic symptoms. Our purpose was to evaluate the frequency of new ischemic lesions found on diffusion-weighted imaging after protected carotid angioplasty and stent placement and to determine the association of new lesions with ICA Doppler flow parameters.MATERIALS AND METHODS:Fifty-two patients (mean age, 68 ± 11 years) with 50%–69% (n = 20, group 1) and ≥70% (n = 32, group 2) internal carotid artery stenosis underwent carotid angioplasty and stent placement with distal filter protection. DWI was performed before and 48 hours after carotid angioplasty and stent placement.RESULTS:Thirty-three (63.4%) patients showed new lesions. The average number of new postprocedural lesions was 3.4 per patient. Most of the postprocedural lesions were <5 mm (range, 3–23 mm), cortical and corticosubcortical, and clinically silent. Group 2 had a significantly higher number of new lesions compared with group 1 (P < .001). A significant relationship was found between ICA Doppler flow parameters and the appearance of new lesions.CONCLUSIONS:The appearance of new ischemic lesions was significantly related to the Doppler flow parameters, particularly peak systolic velocity.

Stroke is the most common life-threatening neurologic disorder and the most important single cause of disability.^1,2 Carotid artery stenosis, a major risk factor for stroke, and distal embolization, arising from degenerative breakdown or thrombotic occlusion of complex plaques, are important mechanisms of stroke in patients with atherosclerotic internal carotid artery stenosis.^3–6 Duplex sonography is currently the principal and, undoubtedly, the most accurate noninvasive and inexpensive diagnostic technique available for the evaluation of internal carotid artery stenosis. It provides information about the presence and severity of carotid stenosis, the velocity and characteristics of blood flow, and plaque morphology.^7–10Carotid angioplasty and stent placement for severe internal carotid artery stenosis have been introduced as a safe alternative to medical and/or surgical treatment in patients at high risk for surgical procedures.^11,12 However, there is still a major concern regarding its safety because of the risk of distal cerebral embolization during the procedure. Recent technical refinements, therefore, have led to the widespread use of carotid artery stenting (CAS) with cerebral-protection devices, markedly reducing thromboembolic complication rates.¹³ Diffusion-weighted MR imaging is a very sensitive and specific technique for diagnosing cerebral ischemia.^14,15 It has been used to detect structural damage of the brain due to cerebral embolism after cerebral angiography, neurointerventional procedures, and carotid endarterectomy.^16,17The purpose of our study was to assess, with DWI, the number, size, and location of new brain lesions after protected CAS and to evaluate the association of these new lesion deficits and Doppler flow parameters of ICA.     

The Timing and Frequency of Complications After Peripheral Percutaneous Transluminal Angioplasty and Iliac Stenting: Is a Change from Inpatient to Outpatient Therapy Feasible?

Purpose: A prospective study was performed to assess the frequency and timing of complications after transluminal angioplasty and stent placement with a view to changing our practice and performing these procedures on an outpatient basis. Method: A total of 266 angioplasties and 51 stent deployments were attempted on 240 consecutive patients. Immediate complications were documented by the radiologists. The timing and nature of any complications during and beyond the first 24 hr were reported by the vascular surgeons. Results: There were 14 complications in 240 patients, giving a complication rate of 4.8% per vessel segment dilated. There were five major and nine minor complications. Eighty-six percent of complications were evident before the patient had left the angiography suite. All complications were evident within 4.5 hr of the procedure. Conclusion: The timing of complications suggests it would be reasonable to perform percutaneous transluminal angioplasties and iliac stenting on an outpatient basis in suitable patients.     

Does Renal Artery Supply Indicate Treatment Success of Renal Denervation?

Purpose

Renal denervation (RDN) emerged as an innovative interventional antihypertensive therapy. With the exception of pretreatment blood pressure (BP) level, no other clear predictor for treatment efficacy is yet known. We analyzed whether the presence of multiple renal arteries has an impact on BP reduction after RDN.

Methods

Fifty-three patients with treatment-resistant hypertension (office BP ≥ 140/90 mmHg and 24-h ambulatory BP monitoring (≥130/80 mmHg) underwent bilateral catheter-based RDN. Patients were stratified into one-vessel (OV) (both sides) and at least multivessel (MV) supply at one side. Both groups were treated on one vessel at each side; in case of multiple arteries, only the dominant artery was treated on each side.

Results

Baseline clinical characteristics (including BP, age, and estimated glomerular filtration rate) did not differ between patients with OV (n = 32) and MV (n = 21). Office BP was significantly reduced in both groups at 3 months (systolic: OV ?15 ± 23 vs. MV ?16 ± 20 mmHg; diastolic: OV ?10 ± 12 vs. MV ?8 ± 11 mmHg, both p = NS) as well as 6 months (systolic: OV ?18 ± 18 vs. MV ?17 ± 22 mmHg; diastolic: OV ?10 ± 10 vs. ?10 ± 12 mmHg, both p = NS) after RDN. There was no difference in responder rate (rate of patients with office systolic BP reduction of at least 10 mmHg after 6 months) between the groups.

Conclusion

In patients with multiple renal arteries, RDN of one renal artery—namely, the dominant one—is sufficient to induce BP reduction in treatment-resistant hypertension.     

Hepatocellular Carcinomas Smaller Than 4 cm Supplied by the Intercostal Artery: Can We Predict Which Intercostal Artery Supplies the Tumor?

Objective

To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images.

Materials and Methods

Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient.

Results

Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; p < 0.001).

Conclusion

We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.     

The Relationship Between Neutrophil–Lymphocyte Ratio and Primary Patency of Percutaneous Transluminal Angioplasty in Hemodialysis Arteriovenous Fistula Stenosis When Using Conventional and Drug-Eluting Balloons

Objective

The aim of this study is to investigate the potential association of neutrophil–lymphocyte ratio (NLR) between primary patency of percutaneous transluminal angioplasty (PTA) in hemodialysis arteriovenous fistula stenosis and type (Conventional and Drug-Eluting) of balloons used in PTA.

Material-Method

This retrospective study consists of 78 patients with significant arteriovenous fistulas stenosis who were treated with PTA by using Drug-Eluting Balloon (DEB) (n = 29) or Conventional Balloon (CB) (n = 49). NLR was calculated from preinterventional blood samples. All patients were classified into two groups. Group A; primary patency <12 months (43/78), Group B; primary patency ≥12 months (35/78). Cox regression analysis and Kaplan–Meier method were used to determine respectively independent factors affecting the primary patency and to compare the primary patency for the two balloon types.

Results

NLR ratio and balloon type of the two groups were significantly different (p = 0.002, p = 0.010). The cut-off value of NLR was 3.18 for determination of primary patency, with sensitivity of 81.4 % and specificity of 51.4 %. Primary patency rates between PTA with DEB and CB displayed statistically significant differences (p < 0.05). The cut-off value was 3.28 for determination of 12-month primary patency with the conventional balloon group; sensitivity was 81.8 % and specificity was 81.3 %. There was no statistical relation between NLR levels and the drug-eluting balloon group in 12-month primary patency (p = 0.927).

Conclusion

Increased level of NLR may be a risk factor in the development of early AVF restenosis after successful PTA. Preferring Drug-Eluting Balloon at an increased level of NLR can be beneficial to prolong patency.

     

Time-of-Flight MR Angiography of Carotid Artery Stenosis: Does a Flow Void Represent Severe Stenosis?

BACKGROUND AND PURPOSE: Time-of-flight (TOF) magnetic resonance angiography (MRA) is commonly used to visualize the carotid arteries; however, flow void artifacts can appear. Our purpose was to determine the frequency and diagnostic meaning of flow voids by using real patient data, as part of a larger study of MRA compared with the criterion standard, digital subtraction angiography (DSA). METHODS: In 1997-2000, 390 consecutive patients with sonographic findings suggestive of carotid artery stenosis were included in this study. All patients subsequently underwent three-dimensional (3D) TOF MRA and conventional DSA. The frequency of flow void artifacts on 3D TOF MRA images were compared with stenosis measurements on DSA images. RESULTS: We recorded 107 flow voids (16%) during 3D TOF MRA of 662 carotid arteries. DSA images were available for comparison in 102 cases. The median percentage of stenosis in this subgroup of flow voids on MRA images was 80%, compared with measurements on DSA images according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Stenoses ranged from 36% to 100% (occlusion). Three flow voids (2.9%) were in the 0-49% range; 11 (10.8%), in the 50-69% range; and 86 (84.3%), in the 70-99% range. Two flow voids (2.0%) represented occlusions. The positive predictive value of a flow void artifact for the presence of severe (70-99%) stenosis was 84.3% (95% CI: 77.3%, 91.4%). CONCLUSION: Flow void artifacts represented severe stenosis in most of the arteries. According to our data, the assumption that flow voids on 3D TOF MRA images represent severe stenosis is justified.     

Can Cell Kinetic Parameters Predict the Response of Tumours to Radiotherapy?

Summary

Three potential predictive assays of the repopulation component in tumour response to therapy are considered. (1) The DNA index can easily be measured. It is of prognostic value for cancers of certain sites, aneuploidy being a bad prognostic indicator. It is not strictly an indicator of cell proliferation. (2) The in vitro labelling index is of predictive value in early stage operable breast cancer and in head and neck cancer. In the former a high pretreatment labelling index can identify patients who could benefit from adjuvant chemotherapy. (3) The tumour potential doubling time can be measured rapidly following in vivo labelling with bromodeoxyuridine or iododeoxyuridine. We have measured T_pot in over 100 solid tumours with a success rate of about 75 per cent. Nearly 50 per cent of the tumours have a pre-treatment potential doubling time of 5 days or less. These would be suitable candidates for accelerated fractionation.     

Diffusion-Weighted Imaging of Nasopharyngeal Carcinoma: Can Pretreatment DWI Predict Local Failure Based on Long-Term Outcome?

BACKGROUND AND PURPOSE:Pretreatment prediction of patients with nasopharyngeal carcinoma who will fail conventional treatment would potentially allow these patients to undergo more intensive treatment or closer posttreatment monitoring. The aim of the study was to determine the ability of pretreatment DWI to predict local failure in patients with nasopharyngeal carcinoma based on long-term clinical outcome.MATERIALS AND METHODS:One hundred fifty-eight patients with pretreatment DWI underwent analysis of the primary tumor to obtain the ADC mean, ADC skewness, ADC kurtosis, volume, and T-stage. Univariate and multivariate analyses using logistic regression were performed to compare the ADC parameters, volume, T-stage, and patient age in primary tumors with local failure and those with local control, by using a minimum of 5-year follow-up to confirm local control.RESULTS:Local control was achieved in 131/158 (83%) patients (range, 60.3–117.7 months) and local failure occurred in 27/158 (17%) patients (range, 5.2–79.8 months). Compared with tumors with local control, those with local failure showed a significantly lower ADC skewness (ADC values with the greatest frequencies were shifted away from the lower ADC range) (P = .006) and lower ADC kurtosis (curve peak broader) (P = .024). The ADC skewness remained significant on multivariate analysis (P = .044). There was a trend toward higher tumor volumes in local failure, but the volume, together with T-stage and ADC mean, were not significantly different between the 2 groups.CONCLUSIONS:Pretreatment DWI of primary tumors found that the skewness of the ADC distribution curve was a predictor of local failure in patients with nasopharyngeal carcinoma, based on long-term clinical outcome.

Nasopharyngeal carcinoma (NPC) is a radiosensitive tumor, but despite recent advances in treatment by using intensity-modulated radiation therapy, local tumor recurrence still occurs in 12% of patients.¹ Recurrent primary tumors deep to the nasopharyngeal wall may be undetectable by endoscopy, and they are difficult to treat. Moreover, only a small percentage of these recurrent primary tumors present early while the tumor is still amenable to salvage surgery.² It would be beneficial to identify patients with resistant NPC so that more aggressive treatment can be given from the outset, such as an additional radiation therapy boost, chemotherapy, or targeted therapy, or these patients can be selected for posttreatment biopsy or closer posttreatment surveillance imaging.Hypoxia and high stromal content are 2 of the factors related to a poor treatment outcome in head and neck cancers. Both micronecrosis, believed to be related to hypoxia, and high stromal content³ may decrease the restriction of the diffusion of water molecules in tumors that is reflected by an increase in the ADC on DWI. Indeed, reports of head and neck squamous cell carcinoma suggest a significant association between high pretreatment ADC and poor treatment outcome.^4–10 However, for NPC, a smaller number of pretreatment predictive DWI studies have been reported. This is probably because local tumor relapse is less common in NPC than in squamous cell carcinoma and is spread out during a longer posttreatment period. Most relapses in squamous cell carcinoma occur in the first 2 years, whereas for NPC, only around 52% of NPCs relapse in the first 2 years, with a further 39% at 2–5 years and 9% after 5 years.¹¹ Currently, most predictive treatment-response NPC studies are based on a relatively short-term outcome ranging up to 3 months posttreatment,^12–14 and only 1 study has reported results based on longer term outcome correlating pretreatment DWI with local relapse-free or disease-free survival at 3 years.¹⁵Therefore, the aim of this study was to determine the diagnostic performance of pretreatment DWI of the primary tumor site for the prediction of local failure (LF) based on long-term follow-up at a minimum of 5 years for patients diagnosed with local control (LC) in NPC.     

Attenuation of Blood Flow Pulsatility along the Atlas Slope: A Physiologic Property of the Distal Vertebral Artery?

BACKGROUND AND PURPOSE:Physiologic and pathologic arterial tortuosity may attenuate blood flow pulsatility. The aim of this prospective study was to assess a potential effect of the curved V3 segment (Atlas slope) of the vertebral artery on arterial flow pulsatility. The pulsatility index and resistance index were used to assess blood flow pulsatility.MATERIALS AND METHODS:Twenty-one healthy volunteers (17 men, 4 women; mean age, 32 years) were examined with a 3T MR imaging system. Blood velocities were measured at 2 locations below (I and II) and at 1 location above the V3 segment (III) of the vertebral artery by using a high-resolution 2D-phase-contrast sequence with multidirectional velocity-encoding.RESULTS:Pulsatility and resistance indices decreased along all measurement locations from proximal to distal. The pulsatility index decreased significantly from location II to III and from I to II. However, the decrease was more pronounced along the Atlas slope than in the straight-vessel section below. The decrease of the resistance index was highly significant along the Atlas slope (location II to III). The decrease from location I to II was small and not significant.CONCLUSIONS:The pronounced decrease in pulsatility and resistance indices along the interindividually uniformly bent V3 segment compared with a straight segment of the vertebral artery indicates a physiologic attenuating effect of the Atlas slope on arterial flow pulsatility. A similar effect has been described for the carotid siphon. A physiologic reduction of pulsatility in brain-supplying arteries would be in accordance with several recent publications reporting a correlation of increased arterial flow pulsatility with leukoencephalopathy and lacunar stroke.

The flow waveform in an arterial vessel is affected by many factors. Main influencing parameters are inflow determinants (cardiac function), outflow determinants (downstream tissue), and resistance presented by the vessel wall.^1–4Due to the different functions of large and small arteries, arterial flow waveforms undergo changes along the vascular tree. The large conduit arteries have an elastic wall to minimize longitudinal impedance.⁵ In contrast, the distal arteries that regulate the demand for blood of the downstream tissue have a more muscular wall to effectively change lumen size.The elasticity of the large arteries has a buffering function, which decreases pressure and flow pulsatility by taking up energy during systole and releasing it during diastole (Windkessel effect), thus delivering blood in a more continuous stream to peripheral vascular beds.⁶ Due to increased wall stiffness, waveform changes occur with normal aging but also in pathologies that affect vascular compliance.⁷ Recent studies with large patient cohorts indicate that the brain is vulnerable to increased arterial pulsatility, reflected by a higher number of white matter hyperintensities and a greater incidence of lacunar strokes.^8–10The most important techniques for noninvasive flow measurements and therefore flow wave characterization are Doppler sonography and phase-contrast (PC) MR imaging. Both techniques are important clinical tools. Doppler sonography has the advantage of a widely available method with very high spatial and temporal resolution; however, it is user-dependent and restricted to sonography-accessible vessel locations.¹¹ Phase-contrast MR imaging, in turn, has the advantage of providing blood flow measurements independent of the user without anatomic restrictions, however, with lower spatial and temporal resolution.^12–14Regarding PC-MR imaging, a 2D-PC sequence with unidirectional velocity-encoding is routinely applied. This sequence is fast and robust; however, due to its unidirectional vessel encoding, it may underestimate flow velocities due to placement errors.¹⁵ Newer techniques such as 4D-PC-MR imaging and 2D-PC-MR imaging with multidirectional velocity-encoding have been shown superior to 2D-PC-MR imaging with unidirectional velocity-encoding in curved vessel sections.^16–19The aim of the present study was to evaluate blood flow characteristics along the curved vessel section of the distal vertebral artery, extending from the transverse foramen C2 to the dura mater cranial to the Atlas vertebra (Atlas slope), to evaluate the effect of a tortuous vessel geometry on blood flow pulsatility. For blood flow and velocity measurements, a 2D-PC sequence with multidirectional velocity-encoding has been applied.     

4D Flow MR Imaging of the Left Atrium: What is Non-physiological Blood Flow in the Cardiac System?

Most cardiac diseases cause a non-physiological blood flow pattern known as turbulence around the heart and great vessels, which further worsen the disease itself. However, there is no consensus on how blood flow can be defined in disease conditions. Especially, in the left atrium, the fact that vortex flow already exists makes this debate more complicated. 3D time-resolved phase-contrast (4D flow) MRI is expected to be able to capture blood flow patterns from multiple aspects, such as blood flow velocity, stasis, and vortex quantification. Previous studies have confirmed that physiological vortex flow is predominantly induced by the higher-volume flow from the superior left pulmonary vein. In atrial fibrillation, 4D flow MRI reveals a non-physiological blood flow pattern, which information may add value to well-established clinical risk factors. Currently, the research target of LA analysis has also widened to lung surgeons, pulmonary vein stump thrombosis after left upper lobectomy. 4D flow MRI is expected to be utilized for many more variable diseases that are currently unimaginable.     

Endovascular Renal Artery Denervation: Why, When, and How?

Endovascular renal artery denervation (ERAD) is a new procedure to reduce renal and systemic sympathetic overactivity in hypertensive patients. The role of sympathetic overactivity is recognized since a long time as being one the contributor of human hypertension. In support of this view, several studies in experimental models of hypertension in animal as well as hypertensive human subjects have demonstrated that sympathetic overactivity plays a central role in hypertension catheter based renal denervation is now possible, and this procedure may provide a useful adjunct for the management of patients with drug-resistant primary hypertension. Following a cohort study, the results of an open label randomized control trial have been published showing very encouraging results. The purpose of this paper is to help interventionalists to better understand the medical and technical issues related to this new intervention. It is most likely that as underlined in a recent editorial several other technical approaches may appear in the future, however because this is the only technique that is available today, we will focus on radiofrequency based technique.     

Does the Pulsatile Non-uniform Flow Matter in MR Flowmetry?

3D cine phase-contrast (4D flow) MRI is a sequence with great potential for non-invasive time-resolved 3D flowmetry at arbitrary vessel sections in various blood vessels. However, it is not widely known that the flowmetry with 4D flow MRI is vulnerable to pulsatile and non-uniform flow. Due to the limited spatial and temporal resolutions, averaging within the 3D voxel is occurring during the flowmetry. A simple solution is to avoid setting the measurement plane in the area where non-uniform flow is dominant, which is possible with an aid of streamline depictions generated by computational fluid dynamics (CFD) or 4D flow MRI data. Unlike 4D flow MRI, flowmetry in CFD simulation can use higher spatial and temporal resolution depending on computer performance; therefore, it is robust to fluctuating non-uniform flow. However, the performance of CFD simulations might be limited due to inlet conditions with low temporal resolution. Difficulty applying complex blood flow such as reflection flow from periphery may also limit accurate simulation. Caution should be taken when comparing the result of CFD simulation to that of 4D flow measurement.     

Determination of the Nonlethal Margin Inside the Visible “Ice-Ball” During Percutaneous Cryoablation of Renal Tissue

Objective

The study was designed to determine the distance between the visible “ice-ball” and the lethal temperature isotherm for normal renal tissue during cryoablation.

Methods

The Animal Care Committee approved the study. Nine adult swine were used: three to determine the optimum tissue stain and six to test the hypotheses. They were anesthetized and the left renal artery was catheterized under fluoroscopy. Under MR guidance, the kidney was ablated and (at end of a complete ablation) the nonfrozen renal tissue (surrounding the “ice-ball”) was stained via renal artery catheter. Kidneys were explanted and sent for slide preparation and examination. From each slide, we measured the maximum, minimum, and an in-between distance from the stained to the lethal tissue boundaries (margin). We examined each slide for evidence of “heat pump” effect.

Results

A total of 126 measurements of the margin (visible “ice-ball”–lethal margin) were made. These measurements were obtained from 29 slides prepared from the 6 test animals. Mean width was 0.75 ± 0.44 mm (maximum 1.15 ± 0.51 mm). It was found to increase adjacent to large blood vessels. No “heat pump” effect was noted within the lethal zone. Data are limited to normal swine renal tissue.

Conclusions

Considering the effects of the “heat pump” phenomenon for normal renal tissue, the margin was measured to be 1.15 ± 0.51 mm. To approximate the efficacy of the “gold standard” (partial nephrectomy, ~98 %), a minimum margin of 3 mm is recommended (3 × SD). Given these assumptions and extrapolating for renal cancer, which reportedly is more cryoresistant with a lethal temperature of ?40 °C, the recommended margin is 6 mm.     

Angioplasty with or without Stent Placement in the Brachiocephalic Artery: Feasible and Durable? A Retrospective Cohort Study

PURPOSE: To evaluate the results of percutaneous transluminal angioplasty (PTA) and stent placement in isolated brachiocephalic trunk lesions. MATERIALS AND METHODS: PTA, with or without stent placement, was used to treat 30 patients with isolated clinically significant stenoses (n = 25) or occlusions (n = 5) of the brachiocephalic artery. Initial clinical success was defined as a relief or substantial reduction of the preprocedural symptoms, and initial technical success was defined as a mean translesion pressure gradient of less than 5 mm Hg or a residual stenosis of less than 20%. Clinical evaluation and duplex Doppler ultrasonography of the lesion site were performed at follow-up. Clinical restenosis was defined as recurrent clinical symptoms and a lumen reduction of more than 50%, determining the primary clinical patency. Technical restenosis was defined as more than 50% lumen reduction with or without renewed clinical symptoms, determining the primary technical patency. RESULTS: The initial technical success rate was 83% (occlusions, 60%; stenoses, 88%), and the clinical success rate was 81%. Two patients had major complications, and four experienced minor complications. At a median follow-up of 24 months (4 weeks to 92 months), the primary clinical patency rate was 79% (95% confidence interval [CI]: 57%, 104%), with 83% (95% CI: 60%, 105%) for arteries with stents and 67% (95% CI: 13%, 120%) for those without stents (P = .11). The primary technical patency rate was 50% (95% CI: 24%, 76%). CONCLUSION: PTA with or without stent placement in a stenotic or occlusive brachiocephalic artery is a procedure of tolerable safety with a high initial success rate; however, only moderately rewarding results were obtained after 2 years. Selective stent placement probably improves long-term success. Primary PTA with selective stent placement in an atherosclerotic obstructive brachiocephalic artery should be considered the preferred treatment option.