Clinical study of 57 cases of endovascular treatment for total subclavian artery occlusion.

OBJECTIVE: To investigate the safety and efficacy of endovascular treatment for totally occlusive lesions of the subclavian artery (SCA). METHODS: A retrospective study was performed on 57 patients treated with angioplasty and stenting, including 42 males and 15 females, with an average age of 61.8 years (range: 49 to 81 years). Efficacy, safety, and complications were evaluated. RESULTS: Procedural success was achieved for 47/57 patients and symptoms were relieved. Rat-tail occlusion is the most common type, and all cases were successfully recanalized. Plain type occlusion is less common with a recanalization rate of 55.6%. Hilly and plain occlusions are the main types of stent implantation failure. Through univariate analysis and trend matching analysis, the type of SCA occlusion and surgical approach had statistical significance on the success rate of surgery. The mean follow-up time was 34.6 ± 16.2 months. The cumulative stent patency rates at 1, 3, and 5 years were 95.5%, 86.4%, and 77.3% in the calcified plaque group and 92.0%, 76.0%, and 68.0% in the non-calcified plaque group, respectively. The 3-year and 5-year patency rates in the calcified plaque group were higher than those in the non-calcified plaque group (p < .05). CONCLUSION: Different occlusion types and surgical approaches can affect the surgical success rate. The combined femoral and brachial approach can improve the rate of recanalization of SCA occlusions. The patency rates at 3 and 5 years in the calcified plaque group were higher than those in the non-calcified plaque group.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Feasibility of Intravascular Lithotripsy for the Treatment of Calcified Supra-Aortic Vessels: A Case Report and Literature Review.

PURPOSE: To report a case of coronary-subclavian steal syndrome (CSSS) due to a history of a left internal mammary artery (LIMA) to left anterior descending (LAD) artery coronary bypass (CABG) and a heavily calcified ostial left subclavian artery (LSA) occlusion, that was treated with intravascular lithotripsy (IVL) technique and to summarize the current trends of IVL treatment for supra-aortic vessels. CASE REPORT: A 64-year-old woman with progressive intermittent angina pectoris and a history of LIMA to LAD bypass underwent coronary angiography which demonstrated complete ostial occlusion of the LSA. Via brachial access, the patient underwent Shockwave IVL balloon treatment of the LSA and stent-graft implantation. At 9 months follow-up, the patient showed symptoms resolution, and duplex ultrasound (DUS) demonstrated a patent LSA. CONCLUSIONS: The Shockwave IVL system was demonstrated to be a feasible treatment and justified for selective cases of highly calcified lesions in supra-aortic vessels. The present case report and the literature review, in a total of 47 patients resulted in a high technical procedural success rate, with a low rate of complications. Future studies with larger cohorts are warranted to confirm these findings and standardize this technology in this particular vascular field. CLINICAL IMPACT: The present study exemplifies a case of recanalization of the left subclavian artery in a patient with coronary-subclavian steal syndrome with a heavily calcified ostial lesion treated with intravascular lithotripsy (IVL). In this paper, for the first time, a review of the contemporary literature on the use of IVL in supra-aortic vessels is reported, elucidating the feasibility of this technique in this vascular territory. Despite the heterogeneous features of the reported cases and the lack of a standardized protocol for the use of IVL in the management of highly calcified lesions of supra-aortic vessels, it was demonstrated to be a feasible technique, with a high technical success rate, being an advantageous tool for heavily calcified supra-aortic lesions.

Cardiac and Vascular Causes of Syncope and Atherosclerosis.

PURPOSE OF REVIEW: Among the most common causes of cardiac syncope are arrhythmias and ischemic heart disease, both of which can coexist. The purpose of this review is to discuss the main causes of cardiac and vascular syncope related to atherosclerosis, its epidemiological and clinical aspects, warning signs, and initial approach. RECENT FINDINGS: Cardiac syncope may have a frequency of up to 34% in elderly people. Atherosclerosis-related causes of cardiac and vascular syncope may be due to cardiac arrhythmia and/or structural impairment of the heart or arteries. Late ventricular tachycardia and late-onset high-grade atrioventricular block associated with myocardial ischemia may occur with syncope, which is related to higher mortality. Besides ventricular dysfunction, concentric remodeling is also a prognostic factor. In calcific degenerative aortic stenosis, syncope carries a worse prognosis than the other cardinal signs. Cardiac syncope has a high recurrence and mortality rate. There are red flag alerts that must be considered in risk stratification.

Acute coronary syndrome following arteriovenous fistula creation in a post CABG patient: A steal phenomenon from coronary artery to subclavian artery.

A 70-year-old man with a history of coronary artery bypass grafting 15 years back and arteriovenous (AV) fistula creation in the left arm 1 month back presented with acute coronary syndrome (ACS). He had not received dialysis before his referral. We felt the most likely etiology for these complaints was increased cardiac oxygen demand from an increased cardiac output related to the newly formed left AV fistula. Coronary angiography was done to detect any significant stenosis in the native or grafted vessels. This revealed that the left subclavian artery was totally occluded in the ostioproximal segment and the coronary arteries did not have occlusions to explain the ACS setting. CT angiography confirmed the angiographic findings of the totally occluded left subclavian artery followed by a well-developed and patent left internal mammary artery to left anterior descending artery. This led to the consideration of a steal syndrome from the coronary artery by the subclavian artery distal to the occlusion. A successful percutaneous endovascular intervention on the left subclavian artery occlusion was performed. Subsequently, the patient became asymptomatic and experienced a dramatic increase in left ventricular ejection fraction.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

Systolic murmur in disguise: subclavian artery stenosis as an overlooked cause of missed case of hypertension.

In this report we present a case of missed hypertension due to subclavian artery stenosis. A 77 year-old female patient, initially thought as being normotensive, was referred to us due to newly discovered systolic heart murmur suspicious for aortic stenosis. We noted inter-arm blood pressure difference of 30 mmHg, with higher, hypertensive values on right arm. Further workup and medical imaging excluded aortic stenosis and revealed an asymptomatic, hemodynamically significant, stenosis of left subclavian artery. Due to absence of symptoms, the patient has been managed with conservative therapy for subclavian stenosis and hypertension, and she is currently in good conditions and followed up for any signs of disease progression. This case clearly shows importance of measuring blood pressure on both arms when initially diagnosing hypertension as this is often overlooked and is key to properly diagnose hypertension and possible subclavian stenosis.

Coronary-subclavian steal syndrome, an easily overlooked entity in interventional cardiology.

Coronary-subclavian steal syndrome (CSSS) is a severe complication of coronary artery bypass graft (CABG) surgery with internal mammary artery grafting. It is caused by functional graft failure due to a hemodynamically significant proximal subclavian artery stenosis. In this manuscript, we provide a comprehensive review of literature and we report a series of five consecutive CSSS cases. This case series illustrates the variable clinical presentation, thereby emphasizing the importance of raised awareness concerning this pathology in CABG patients.

Coronary Subclavian Steal Syndrome: A Contemporary Review.

Coronary subclavian steal syndrome (CSSS) is a rare cause of angina. It occurs in patients with prior coronary artery bypass grafting and, specifically, a left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. In this context, there is retrograde blood flow through the LIMA to LAD graft to supply the subclavian artery beyond the significant stenosis. This potentially occurs at the cost of compromising coronary artery perfusion dependent on the LIMA graft. In this review, we present a case of a middle-aged female who suffered from CSSS and review the literature for the contemporary diagnosis and management of this condition.

[Surgical treatment of total subclavian artery occlusion: a single center experience of 67 cases].

Objective: To examine the outcomes of surgical repair for patients with total subclavian artery occlusion. Methods: A retrospective analysis was performed on 67 patients with subclavian artery occlusion disease admitted at Ward 1 of Aortic and Vascular Surgery Center, Fuwai Hospital from January 2016 to July 2019. The age was, and There were 51 male patients and 16 females with an age of (61.7±8.2) years (range: 37 to 79 years). The t-test, Mann-Whitney U-test, χ(2) test, and Fisher's exact test were used to analyze the factors related to the technique success. The Kaplan-Meier curve was used to calculate the cumulative patency rate and plot the corresponding survival curves, and the Log-rank test was used for comparison. The length from the subclavian artery ostial to the occlusion area was used as a variable to plot the receiver operating characteristic curve, and the optimal cut-off value was determined by the Youden index. Results: Eighteen patients received open surgery. Forty-nine patients with subclavian artery occlusion accepted endovascular repair, of which 38 patients succeeded (31 cases on left side and 3 cases on right side). Fifteen patients failed with endovascular therapy, of which 10 cases received elective surgery and 5 cases received conservative therapy. The success rate of endovascular repair was 69.4%(34/49). Among them, the success rate of left subclavian artery occlusion was 81.6%(31/38), while the right side was 3/11. Patients with the length from the subclavian artery ostial to the occlusion area ≥6 mm were more likely to get success (23/34 vs. 4/15, χ(2)=5.506, P=0.019). In the endo-group, one patient had hemorrhage in the left chest. In the open-group, one patient had lymphatic leakage. Follow-up period ranged from 3 to 46 months with a median of 22 months. The patency of endovascular repair group and the open surgery group was 92.6% and 90.8% at 12-month, while 82.9% and 84.3% at 24-month, respectively. The cumulative patency rates of smoking patients and non-smoking patients after endovascular treatment were 70.2% vs. 100% (P=0.048) at 24-month. No independent prognosis factors were identified through the Cox proportional risk model which significantly affected postoperative patency rates for patients with subclavian artery occlusion. Conclusions: Part of patients with subclavian artery occlusion can be treated by endovascular therapy. The success rate of left subclavian artery occlusions is higher than right sides. The length from the subclavian artery ostial to the occlusion area affected the success rate of repair.

Damage control for subclavian artery injury.

Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.

[Optimal method of reconstruction in patients with pathology of the 1st segment of the subclavian artery]. / Optimal'nyi metod rekonstruktsii u patsientov s patologiei 1 segmenta podkliuchichnoi arterii.

The study enrolled a total of 318 patients presenting with lesions of the 1st segment of the subclavian artery and the clinical course of vertebrobasilar insufficiency. All patients prior to admission had been receiving the best course of medicamentous therapy under the supervision of a neurologist for more than 6 months but with no significant clinical improvement. According to the type of the reconstructive operation on the 1st segment of the subclavian artery, all patients were subdivided into three groups. Group I included 48 (15.1%) patients presenting with occlusion of the subclavian artery and undergoing carotid subclavian bypass grafting. Group II consisted of 224 (70.4%) patients who underwent endarterectomy from the subclavian artery and its transposition to the common carotid artery. Group III was composed of 46 (14.5%) patients presenting with local stenosis of the subclavian artery and subjected to stenting of the 1st segment of the subclavian artery. The main criteria for assessment of the results were patency of the zone of reconstruction and clinical improvement of the patient after surgery. RESULTS: Clinical improvement in the early postoperative period was observed in 301 (94%) patients. In Group I, in the early postoperative period, clinical improvement was achieved in 32 (66.7%) patients. Clinical improvement after 3 years persisted only in 16 (33.3%) patients. In Group II comprising patients with transposition of the subclavian artery to the common carotid artery, clinical improvement was observed in 223 (99.6%) patients. Within 3 years of follow-up, 13 (6.4%) patients were found to have a relapse of the clinical picture of vertebrobasilar insufficiency. Clinical improvement after transposition of the subclavian artery to the common carotid artery at 3 years persisted in 210 (93.6%) patients. In Group III patients after stenting of the 1st segment of the subclavian artery in the early postoperative period and during the follow-up period up to 1 year, the angiographic and clinical success amounted to 100%. After 3 years, 8 (17.3%) patients developed relapse of the clinical course because of restenosis, fracture, and thrombosis of the stent. Clinical improvement at 3 years persisted only in 38 (82.6%) patients after stenting. Comparing the remote results demonstrated that transposition of the subclavian artery to the common carotid artery turned out to be the most justified (p<0.05). CONCLUSION: For reconstruction of the 1st segment of the subclavian artery, an operation of choice is transposition of the subclavian artery to the common carotid artery.

High incidence of progressive stenosis in aberrant left subclavian artery with right aortic arch.

Right aortic arch with aberrant left subclavian artery (RAA/aLSCA) is a rare aortic arch anomaly. The clinical association of aLSCA stenosis with RAA/aLSCA has not yet been fully elucidated. The aim of this study was to investigate the diagnosis, incidence, management and outcome of aLSCA stenosis in infants with prenatally diagnosed RAA/aLSCA. Ten fetuses who were diagnosed as having RAA/aLSCA in Kyushu University Hospital between January 2011 and December 2014 were enrolled. The maternal and child medical records were reviewed to investigate sex, gestational age at the fetal diagnosis, gestational age and body weight at birth, the findings of computed tomography (CT), Doppler ultrasonography of the vertebral artery and angiography, and the complications and outcomes of aLSCA stenosis. In 8 of 10 patients, aLSCA stenosis was identified on the first CT examination after birth. No patients had dysphagia or respiratory distress. The stenosis spontaneously resolved in 3 patients. In 4 of the 5 remaining patients, aLSCA stenosis progressed, including one case in which complete occlusion occurred-the case was associated with retrograde flow from the left vertebral artery supplying the distal LSCA. Balloon angioplasty was successfully used to treat stenosis in two cases. The subclavian steal phenomenon and developmental problems were not observed in any patients. aLSCA stenosis was identified in 80% of patients with RAA/aLSCA after birth. The early detection and elective treatment of stenotic lesions may be required to prevent complete occlusion during the development of the cardiovascular and cerebrovascular systems.

Thoracic epidural haematoma due to a subclavian steal syndrome and secondary formed thoracic collateral circuits, coincidence or consequence: a case report.

Despite profound diagnostics, the aetiology of spinal epidural haematoma (SEH) often remains unknown. In this case, diagnostics revealed an SEH at the fifth and sixth thoracic levels due to a subclavian steal syndrome with a tortuous vascular loop between the sixth thoracic intercostal artery and the costocervical arteries deriving from the left subclavian artery with plump arteries in the epidural space. The patient underwent decompression surgery and a percutaneous transluminal angioplasty. The patient showed good recovery at follow-up. The SEH was a result of secondary formed thoracic collateral circuits with epidural involvement due to a subclavian steal syndrome.

Subclavian artery stenting for coronary-subclavian steal syndrome.

OBJECTIVES: To evaluate the safety and feasibility of subclavian artery stenting for coronary-subclavian steal syndrome (CSSS). BACKGROUND: CSSS is a rare cause of myocardial ischemia due to ipsilateral subclavian artery stenosis in patients who have undergone coronary artery bypass graft. However, current knowledge of the optimal therapy for CSSS is limited. METHODS: The clinical data of 37 patients (33 male; mean age 65 ± 6 years) with CSSS who had undergone subclavian artery stenting between April 2007 and December 2015 were analyzed. RESULTS: The time elapsed between bypass surgery and the diagnosis of CSSS was 6.3 ± 4.3 years (median 5.2 years, range 1.3 months to 17.8 years). The technical success rate was 97.3% (100% for stenosis, 85.7% for occluded lesions). One patient experienced a transient ischemic attack; a second patient developed flow-limiting dissection involving the ostium of the internal mammary artery; and a third patient had a puncture site hematoma. The mean stenosis of target lesions decreased from 87.6 ± 10.6% to 5.9 ± 5.0% immediately after the procedure. A total of 35 (94.6%) patients were discharged with a complete remission of myocardial ischemia. During a follow-up of 44 ± 32 (range 6-112) months, no patient suffered from stroke or myocardial infarction. Stent-restenosis related unstable angina developing in one patient at 36 months and in another patient at 11 months, both of whom were relieved after balloon angioplasty and remained asymptomatic until the last follow-up. CONCLUSION: Subclavian artery stenting is feasible and safe in patients with CSSS, with a low incidence of perioperative complications and stent restenosis rate. © 2017 Wiley Periodicals, Inc.

Coronary Subclavian Steal Syndrome Successfully Treated with Subclavian Artery Stenting: A Report of 2 Cases.

Coronary subclavian steal syndrome (CSSS) is a well-recognized phenomenon secondary to coronary artery bypass grafting and may cause myocardial ischemia. We report 2 cases of CSSS successfully treated with subclavian artery (SA) stenting. In both cases, an Optimo balloon guiding catheter was placed in the SA immediately proximal to the vertebral artery (VA) origin as a double protection system for the VA and left internal thoracic artery (LITA) graft. There were no periprocedural complications. Balloon protection for both the VA and LITA using a single balloon guiding catheter is a reasonable and safe technique for preventing distal embolisms.

Endovascular Treatment of the Subclavian Artery Steno-Occlusive Disease.

OBJECTIVE: The aim of our study was to compare immediate and long-term results of endovascular interventions for the treatment of steno-occlusive disease of subclavian arteries (SAs) depending on the length of lesion. MATERIALS AND METHODS: Between 2010 and 2013, we performed 245 endovascular procedures to treat patients with atherosclerotic steno-occlusive disease of SAs. All patients were examined and subdivided according to the received results into 2 groups: 125 patients with stenosis of SA were included in the first group and 120 patients with occlusion of SA were included in the second group. The patients were then followed up at 6, 12, 24, 36, and 48 months after endovascular interventions. Follow-up visits contained symptomatic evaluation, clinical assessment with physical examination, complete neurological evaluation, and serial color Doppler ultrasonography. RESULT: Transitory ischemic attacks in the vertebrobasilar system were intraoperatively developed by 1 patient from the first group (.8%) and 3 patients from the second group (2.5%). Reinterventions in the long-term period were carried out in 9 (7.2%) cases in the first group and 12 (10%) cases in the second group (P = .43). The cumulative primary stent patency at 4 years was 89.8% in the first group and 87% in the second group (P = .4). CONCLUSIONS: In the case of SA occlusion on the first stage, it is expedient to carry out endovascular recanalization followed by stenting. Our study revealed an increased risk of stent thrombosis or in-stent restenosis in patients with stents >40 mm.

[Angina Recurrence After Coronary Artery Bypass Grafting Caused by the Coronary-Subclavian Steal Syndrome].

We present two cases of surgical treatment of patients with coronary artery steal syndrom and multifocal atherosclerosis, who previously underwent coronary artery bypass grafting using left internal mammary artery. In both cases carotid-subclavian bypass was performed through supraclavicular access using synthetic prosthesis. This method allowed to restore blood flow in the left internal mammary artery, eliminate recurrent angina pectoris, and improve patients quality of life. The article also contains descriptions of possible methods of surgical correction of this pathology, their advantages and disadvantages.

Stenting for left subclavian artery stenosis in patients scheduled for left internal mammary artery-coronary artery bypass grafting.

OBJECTIVES: To evaluate the early and long-term outcomes of stent placement for left subclavian artery stenosis (LSAS) in patients scheduled for left internal mammary artery-coronary artery bypass grafting (LIMA-CABG). BACKGROUND: Few studies have demonstrated the safety and effectiveness of endovascular therapy for the treatment of LSAS before LIMA-CABG; therefore, use of this therapy requires further exploration and evaluation. METHODS: Between February 2000 and April 2014, the clinical data of 167 consecutive patients (mean age 64 ± 9 years, 141 males) scheduled for LIMA-CABG with LSAS who were treated by stenting at the Fuwai Hospital were collected and analyzed retrospectively. RESULTS: The technical success rate of the procedure was 97.6% (163/167). The mean stenosis of target lesions decreased from 86.5 ± 9.9% to 7.6 ± 4.6% (P < 0.001). The incidences of death, stroke, and myocardial infarction, as well as the combined incidence of death, stroke, and myocardial infarction from the time of stenting to 30 days after the stenting procedure were 0.6% (n = 1), 1.8% (n = 3), 0% (n = 0), and 1.8% (n = 3), respectively. The 10-year rate of follow-up was 94.6%. The overall survival rate was 98.8% at 1 year, 97.5% at 2 years, 93.9% at 5 years, and 86.2% at 10 years. A total of 14.1% (23/163) of patients developed in-stent restenosis. Stent restenosis-related angina and myocardial infarction were observed in 13 and 3 patients, respectively. The patency rates of the left subclavian artery were 95.7, 93.8, 86.5, and 75.2% at 1, 2, 5, and 10 years, respectively. The target vessel reconstruction rate was 8.0% (13/163). CONCLUSIONS: Stenting of LSAS at experienced medical centers for patients scheduled for LIMA-CABG was safe and effective with a low incidence of complication and in-stent restenosis.

Diagnostic Performance of Combined Contrast-Enhanced Magnetic Resonance Angiography and Phase-Contrast Magnetic Resonance Imaging in Suspected Subclavian Steal Syndrome.

PURPOSE: The study sought to evaluate the efficacy of magnetic resonance imaging (MRI) in patients with suspected subclavian steal syndrome (SSS) using both contrast-enhanced (CE) MR angiography and phase-contrast (PC) MRI. METHODS: Fifteen suspected SSSs from 13 patients were evaluated using CE-MR angiography and PC-MRI. Ten patients also received dynamic CE-MR angiography. RESULTS: All MRI examinations were technically successful. By combining CE-MR angiography with PC-MRI, 10 SSSs were diagnosed in 9 patients. The delay enhancement dynamic technique predicted SSS with a sensitivity, specificity, and accuracy of 57.1%, 100%, and 72.7%, respectively. Without the dynamic technique, affected delay-enhanced arteries were poorly visualized and could be mistaken for occluded vessels. Retrograde vertebral flow by PC-MRI was used to predict ipsilateral SSS with a sensitivity, specificity, and accuracy of 100%, 60%, and 86.7%, respectively. There were 2 false positives including 1 patient with a proximal total occlusion of the affected vertebral artery and another with brachiocephalic steal syndrome rather than SSS. This suggested that retrograde vertebral flow does not always indicate SSS. CONCLUSIONS: CE-MR angiography combined with PC-MRI is efficacious when evaluating SSS in clinical practice.