A 13-year-old girl was diagnosed Takayasu arteritis. She had severe hypertension due to bilateral renal artery stenosis. She was placed bilateral renal artery stenting and was discharged home with medicatons consist of Methotrexate, prenisolon, furosemide, nifedipine, aspirin and clopidogrel. She was lost of follow up for 2 years and cameback outpatient clinic. Clinical examination showed blood pressure of right hand was 100/50 mmHg and unmeasured in left arm with left radial pulselessness

Upper limb Doppler ultrasound showed severe stenosis of left subclavian artery without inside flow. Transthoracic echocardiography (TTE) indicated normal of heart’s structure and function. Biomarkers of inflammation was normal in range.

5F introducer sheath was inserted into the right femoral artery. The 5F Pigtail catheter and 0.035’’ Terumo guidwire were placed in aorta to do segmental aortography from aortic arch, thoracic aorta, abdominal aorta, respectively. It was showed severe obtruction of left subclavian artery. A 4F JR catheter was placed in ostium of subclavian artery for selective angiography. A 0.014’’ guidewire was advanced to find the true lumen of the artery but unpredictable whether it was true lumen. It was kept inside there and a 0.014’’ CTO guidewire was used to find another direction. After many attempts, the CTO guidewire was advanced a segment far enough. Hand injection via 2.4F microcatheter was done to confirm the true lumen of subclavian artery successfully. A 0.014’’ guidewire was advanced to distal as far as possible. A 2.0 mm, 3.5 mm, 4.0 mm, 5.0 mm balloon was advanced to dilate gradually the brachial artery, axillary artery and subclavian artery, respectively. An angiography was done to indicate that the blood flow through the lesion was improved but the arterial wall was thickened irregularly. Therefore, we decided to implant stenting. A 7F Guiding catheter was used to support advance the stent to the optimal site for stenting. 4.5*13 mm (two stents), 5.0*19 mm, 6.0*19 mm, 6.0*15 mm and 7.0*15 mm stent were implanted from distal to proximal segment of subclavian artery, respectively. An angiography was done again to confirm the good blood flow in subclavian artery.

Subclavian artery obstruction is a rare complication in Asian children with Takayasu arteritis. It can be detected early by physical exams and Doppler ultrasound. Chronic obstruction lesion may be rescue by transcatheter intervention. CTO guidewire is helpful in crossing through the lesion and finding the true lumen of the artery. Ballon dilation is feasible and effective to recanalization of the blood flow but may be insufficiency. Stenting may be effective to remain the blood flow and avoid recurrent stenosis for a long time.