Stenting for subclavian steal phenomenon to restore cerebral perfusion due to acute carotid occlusion following carotid endarterectomy: a case report.

BACKGROUND: Perioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting. CASE PRESENTATION: A 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow. CONCLUSION: Subclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering.

[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Stealing from the Heart: A Rare Case of Chest Pain Post-Coronary Artery Bypass Grafting.

A 70-year-old veteran with prior triple vessel coronary artery bypass grafting (CABG) presented with exertional chest pain. His work-up revealed > 40 mm Hg bilateral upper extremity blood pressure difference. Chest computed tomography and invasive angiography revealed severe stenosis at the ostium of the left subclavian artery, proximal to the origin of the left internal mammary artery to left anterior descending artery graft (LIMA-LAD). A diagnosis of coronary subclavian steal syndrome (CSSS) was made, and carotid-subclavian bypass was performed. This case outlines when to suspect CSSS, an approach to its diagnosis, and the importance of its timely management.

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.

Variant of subclavian steal syndrome: unusual anatomical relationship between left subclavian artery and left vertebral artery.

A woman in her 70s presented to her general practitioner (GP) with a 3-month history of left upper arm pain and weakness. A significant difference in bilateral blood pressures was noted and a further history elicited coolness in her left arm without functional compromise. A CT angiography revealed variant subclavian steal syndrome with a subclavian arterial stenosis, which was proximal to both the internal mammary and thyrocervical trunk and her left vertebral artery originating from the aortic arch. She was referred to a vascular surgeon but declined surgical intervention. Her symptoms remain stable with 6-month follow-up from her GP. This case highlights the importance of considering vascular aetiologies in upper limb pain and weakness. Our case reviews the differential diagnoses of upper limb pain and weakness, consequently leading to the discussion of an interesting variant of subclavian stenosis.

Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion.

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Coronary-subclavian steal syndrome causing myocardial infarction after arteriovenous fistula creation: a case report.

Coronary subclavian steal syndrome (CSSS) caused by left subclavian artery (LSA) stenosis is a rare cause of myocardial infarction in patients having coronary artery bypass grafting (CABG), and it has also been observed after an arteriovenous fistula (AVF) was made. A 79-year-old woman who had undergone CABG years earlier and an AVF creation 1 month before experienced a non-ST-elevation myocardial infarction (NSTEMI). While selective catheterization of the left internal thoracic artery graft was impossible, a computed tomography scanner showed patency of all bypasses and proximal subocclusive LSA stenosis, and the digital blood pressure measurements objectified a haemodialysis-induced distal ischaemia. LSA's angioplasty and covered stent placement were successfully performed, resulting in symptom remission. A CSSS-induced NSTEMI due to a LSA stenosis aggravated by a homolateral AVF several years after CABG has been documented only infrequently. If vascular access is required in the presence of CSSS risk factors, the contralateral upper limb should be preferred.

Assessment of the relationship between monocyte to high-density lipoprotein ratio and subclavian artery stenosis.

OBJECTIVE: Assessment of the monocyte-to-high-density lipoprotein ratio (MHR) is a new tool for predicting inflammation, which plays a major role in atherosclerosis. Subclavian artery stenosis (SAS) is usually asymptomatic, and atherosclerosis is the most common cause of chronic obstruction of the subclavian artery in adults. The aim of this study was to determine the relationship between the MHR and SAS. PATIENTS AND METHODS: Between January 2015 and January 2020, 43 patients with SAS and 43 patients without SAS were enrolled in the study. The patients' angiographic, demographic and clinic characteristics were reviewed from their medical records. Monocytes and HDL (high-density lipoprotein) cholesterols were measured through a complete blood count. The MHR was calculated as the ratio of the absolute monocyte count to the HDL cholesterol value. The resulting MHR values were divided into the following three groups: low (7.16 ± 1.59), moderate (11.08 ± 1.53) and high (21.70 ± 5.62). A p-value of less than 0.05 was considered significant. RESULTS: MHR was found to be significantly higher in the SAS group compared to the control group with normal subclavian arteries (p<0.001). The frequency of SAS was found to increase with an increase in the MHR tertiles. Sensitivity and specificity values were 69.8% and 95.3%, respectively. The cut-off of the MHR value, taken as 13.39, was found to provide a significantly accurate prediction of the subclavian diagnosis (ROC area under the curve: 0.868, 95% CI: 0.789-0.947, p<0.001). After adjusting for other hematological parameters in the multivariate analysis, MHR (p=0.061) was found to be a predictor of the presence of SAS. CONCLUSIONS: This study showed that MHR can be a convenient marker for predicting SAS because of the correlation between MHR and SAS.

Frequency of subclavian artery stenosis in patients with mammarian artery coronary bypass and suspected coronary artery disease progression.

We retrospectively analyzed patient records of all patients with a history of internal mammarian artery (IMA) coronary bypass undergoing coronary angiography at two cardiovascular centers between January 1st 1999 and December 31st 2019. A total of 11,929 coronary angiographies with or without percutaneous coronary intervention were carried out in 3921 patients. Our analysis revealed 82 (2%) patients with documented subclavian artery stenosis. Of these, 8 (10%) patients were classified as having mild, 18 (22%) moderate, and 56 (68%) severe subclavian artery stenosis. In 7 (9%) patients with subclavian artery stenosis, angiography revealed occlusion of the IMA graft. 26 (32%) patients with severe subclavian artery stenosis underwent endovascular or surgical revasculararization of the subclavian artery. In this retrospective multicenter study, subclavian artery stenosis was a relevant finding in patients with an internal mammarian artery coronary bypass graft undergoing coronary angiography. The development of dedicated algorithms for screening and ischemia evaluation in affected individuals may improve treatment of this potentially underdiagnosed and undertreated condition.

Subclavian Steal Phenomenon Associated With Vascular Ring in an Infant Who Had a Prenatally Diagnosed Right Aortic Arch With an Atretic Aberrant Left Subclavian Artery.

Vascular ring is a rare congenital anomaly in which the abnormal origin of the aorta or its branches and pulmonary arteries leads to encircling and compression of the trachea and esophagus. A right aortic arch (RAA) with an aberrant left subclavian artery is one of the most common forms of vascular ring. Here, we report a case of a prenatally diagnosed vascular ring resulting from an RAA with an aberrant left subclavian artery. When the infant was 7 months of age, the development of noisy breathing prompted further evaluation with cardiac magnetic resonance imaging that showed an atretic left subclavian artery associated with collateral retrograde flow from the left vertebral artery to the distal portion of the subclavian artery. Our findings indicate that an untreated RAA with an aberrant left subclavian artery may be associated with an increased risk of developing subclavian artery steal syndrome.

Coronary Subclavian Steal Syndrome in a 73-Year-Old Woman Presenting with Angiographically Confirmed Subclavian Artery Stenosis Proximal to the Left Internal Mammary.

BACKGROUND Coronary subclavian steal syndrome (CSSS) is an uncommon condition in which a high-grade stenosis of the subclavian artery proximal to an internal mammary artery bypass graft results in retrograde blood flow of the bypass graft. This report is of CSSS in a 73-year-old woman who presented with ventricular tachycardia and angiographically confirmed subclavian artery stenosis proximal to the left internal mammary artery (LIMA) bypass graft 3 years following coronary artery bypass grafting (CABG). CASE REPORT The patient was a 73-year-old woman with a past medical history of multivessel coronary artery disease, found on preoperative evaluation. She underwent 2 vessel CABG in 2018. She was found to have ischemic cardiomyopathy, ejection fraction of 30% to 35% despite revascularization, and an implantable cardiac defibrillator (ICD). Three years following uncomplicated CABG, the patient presented with angina and sustained ventricular tachycardia; ICD therapy was unsuccessful. Ischemia was the etiology of the sustained ventricular tachycardia, and the patient underwent cardiac catheterization, demonstrating high-grade subclavian artery stenosis proximal to the LIMA bypass graft. Intervention of the 80% lesion of the native left anterior descending artery was done with placement of a 2.75×16-mm drug-eluting stent. The patient responded well to treatment, with no subsequent ventricular tachycardia on outpatient follow-up. CONCLUSIONS This report has shown that in patients who present with symptoms of acute coronary syndrome and a history of CABG involving the LIMA, the possibility of CSSS should be considered and investigated by coronary artery imaging so that diagnosis and management are not delayed.

Endovascular therapy for steno-occlusive subclavian artery disease early and long-term outcomes in a multicentric Tunisian study.

AIM: To evaluate the outcomes of endovascular therapy in patients with subclavian steno-occlusive disease over the short and long term in a Tunisian population. MATERIALS AND METHODS: Patients who underwent endovascular treatment of subclavian artery (SCA) steno-occlusive disease between 2013 and 2019 in three Tunisian centers were evaluated retrospectively. After treatment, patients were follow-up was scheduled at 1, 3, 6, 12 months postoperatively and annually afterwards by Doppler ultrasound and clinical findings. Primary outcomes included technical, clinical procedural success rates and limb salvage rate. Secondary outcomes included the occurrence of periprocedural complications and primary patency rates. RESULTS: 56 patients (33 males, 58.9%) were evaluated. Patients' mean age was 61.5 + years. Technical success rate was 94.6 %, being 100% in case of stenosis and 78.5% in case of occlusion. The technical success rate was 94.6%. The clinical success rate was 100% and the upper limb salvage rate was 100%. Minor amputations were performed on 5 patients. Perioperative mortality and morbidity rates were 0% and 8.9% respectively. Mean follow-up was 26.7±16.4 months (range 12-86 months). Two in-stent restenosis occurred (at 12 and 15 months) and one case of thrombosis at the 16th month. The primary patency rates were 88.7%+4.3% at the end of the first year and 78.7%+6.1% at 3 years. CONCLUSION: Endovascular treatment can be considered as a safe and effective treatment of SCA steno-occlusive disease, with low perioperative complication rates and a good patency rates over long term. KEY WORDS: Subclavian artery stenosis, Subclavian artery occlusion, endovascular, subclavian revascularization.

A Great Heist: Subclavian Steal Syndrome Causing Posterior Transient Ischemic Attack and Stroke.

Introduction Subclavian steal syndrome is a phenomenon of arterial flow reversal secondary to occlusive disease in proximal subclavian arteries, occasionally resulting in neurologic sequelae. Case Presentation The authors present the case of a 67-year-old man with stroke risk factors and a history of receiving head and neck radiation therapy who developed subclavian steal physiology leading to a transient ischemic attack and posterior circulation stroke. He was medically optimized without substantial progression or recurrence of disease. Conclusion This case illustrates a case of vertebrobasilar transient ischemic attack and posterior circulation stroke from subclavian steal syndrome in the setting of prior radiation therapy manifesting as extremity weakness and discoordination. Further research on therapeutic radiation dosages and subsequent incidence of arterial disease which could contribute to subclavian steal syndrome is necessary.

Critical analysis of vertebral artery flow patterns/subclavian steal detected by cerebrovascular duplex ultrasound examinations and its clinical implications.

BACKGROUND: The prevalence of subclavian steal (defined as retrograde/bidirectional vertebral artery flow) in the general population and in patients undergoing cerebrovascular duplex ultrasound (CDUS) examinations is variable. This is the largest study to date to analyze the incidence of duplex-suggested subclavian steal in 5615 CDUS examinations over a 1-year period and to examine its clinical implications. PATIENT POPULATION AND METHODS: All consecutive CDUS examinations performed over a 1-year period were analyzed for the presence of subclavian steal. Indications of testing, presence of posterior cerebral circulation/subclavian steal symptoms, and any interventions for subclavian steal were analyzed. RESULTS: A total of 171 of 5615 (3.1%) CDUS examinations were found to have subclavian steal (duplex-suggested). One hundred seventeen (2.1%) had retrograde flow and 54 (1%) had bidirectional flow. Of 171, 104 (60.8%) were left sided. Indications for CDUS were post-carotid endarterectomy/carotid artery stenting surveillance in 39 patients (22.8%), surveillance for progression of carotid stenosis in 76 patients (44.4%), transient ischemic attack/stroke in 26 patients (15%), asymptomatic screening/carotid bruit in 18 patients (10.5%), and isolated posterior cerebral circulation symptoms in 12 patients (7%). A total of 63% patients had associated >50% carotid stenosis. The mean arm Doppler pressure gradient was 32.2 mm Hg for asymptomatic patients vs 37 mm Hg for patients with posterior circulation symptoms (P = .3254). There were significant differences between the mean systolic arm pressure for patients with retrograde vs antegrade vs bidirectional flow (105 mm Hg vs 146 mm Hg vs 134 mm Hg, respectively, P < .0001). All patients with retrograde flow had >50% subclavian stenosis or occlusion (100 of 117 had subtotal/total occlusion) except for one patient. Meanwhile, 52 of 54 patients with bidirectional flow had >50% subclavian stenosis (6 of 54 with subtotal/total occlusion), whereas two patients were normal/<50% stenosis (P < .0001). Overall, 26 of 171 patients (15.2%) had interventions for disabling symptoms. Eleven of 26 of all interventions were for disabling arm claudication, and only 10 of 171 patients (5.8%) were intervened for disabling posterior circulation symptoms with complete resolution of symptoms in all except one. At a late follow-up with a mean of 18 months (range: 1-37 months), there was no late major stroke with only two lacunar infarcts (not subclavian steal related). There were also seven late deaths, none stroke related. CONCLUSIONS: The incidence of subclavian steal in patients who undergo CDUS is relatively rare. Most of these patients are asymptomatic and can be treated conservatively, and only a few may need intervention for disabling symptoms with good symptom resolution.

Headache may be the only symptom of subclavian steal syndrome after thoracic endovascular aortic repair.

Thoracic endovascular aortic repair (TEVAR) is currently the treatment of choice for thoracic aortic disease. In select cases, the TEVAR stent must occlude the left subclavian artery. This is usually well tolerated, but the subclavian steal syndrome (SCSS) may occur. Vertebrobasilar insufficiency can cause headaches, but reports of headache as the only symptom of SCSS are very rare. Thus, this may be under-recognised. To increase the awareness of this complication we describe the course of a patient who developed chronic intermittent headaches after intentional occlusion of the left subclavian artery with a TEVAR stent. Revascularisation may be required to prevent adverse neurological outcomes from SCSS. Some authors recommend prophylactic revascularisation whenever the left subclavian artery is sacrificed during TEVAR. However, transposition or bypass of this artery is not without risk and mild symptoms, such as secondary headache, can be fully controlled with conservative measures that reduce steal pathophysiology.

Subclavian steal phenomena in right-sided aortic arch with isolated left subclavian artery as demonstrated by quantitative-MRA.

Right-sided aortic arch with an isolated left subclavian artery is a very rare congenital anatomical variant that can lead to subclavian steal syndrome. We present a case of an asymptomatic patient who was incidentally found to have this variant on CT angiography with QMRA evidence of retrograde flow in the left vertebral artery consistent with subclavian steal phenomena. Since patients often remain asymptomatic until their compensatory mechanisms become compromised later in life, serial monitoring using non-invasive hemodynamic studies such as QMRA may guide treatment.

Point-of-care ultrasound for stroke patients in the emergency room.

Stroke requires rapid determination of the cause to provide timely and appropriate initial management. Various ultrasonographic techniques have been evaluated as ways to determine the cause of stroke; among them, carotid artery ultrasonography is particularly useful since it provides considerable information within a short time period when used to evaluate a specific site. In the emergency room, carotid artery ultrasonography can be used to diagnose internal carotid artery stenosis, predict an occluded vessel, and infer the cause of ischemic stroke. Additionally, carotid artery ultrasonography can diagnose different conditions including subclavian artery steal syndrome, bow hunter's stroke, Takayasu's arteritis, moyamoya disease, and dural arteriovenous fistula. Furthermore, patients with ischemic stroke with a pulse deficit or hypotension must be differentiated from acute type A aortic dissection, which requires emergency surgery; carotid artery ultrasonography can immediately differentiate between the two conditions by identifying the intimal flap of the common carotid artery. The following article provides an overview of carotid artery ultrasonography performed as point-of-care ultrasound in the emergency room in patients with suspected stroke.