[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 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.

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.

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.

Isolated reversal of flow in the vertebral artery - A missed entity.

Isolated reversal of flow in the vertebral artery is a rare phenomenon occurring in the general population and is due to intrinsic anatomical defects. The most common cause is subclavian stenosis; however, reversal of flow in the vertebral artery can occur regardless of any detection of anatomic deterioration. In this series, we report three asymptomatic cases where the extracranial Doppler scan preceding off-pump coronary arterial bypass grafting showed isolated reversal of flow in the vertebral artery. No signs of subclavian stenosis or steal syndrome were elicited. However, all patients subsequently suffered from a posterior circulation stroke following off-pump coronary arterial bypass grafting but recovered fully with medical management. We conclude that a detailed pre-operative neurological investigation can mitigate this risk and improve neurological outcomes following off-pump coronary arterial bypass grafting.

Carotid Subclavian Bypass for the Treatment of Coronary Subclavian Steal Syndrome.

Coronary subclavian steal syndrome is an uncommon cause of angina in patients with a previous coronary artery bypass graft procedure. The patient had chest pain with the exertion of the left upper limb, difference in blood pressure between the left and right arm, occlusion at the ostium of the left subclavian artery. He underwent carotid subclavian bypass surgery that was successful in relieving symptoms. On the other hand, the patient had an embolic stroke related to the procedure and further assessment may be necessary.

The use of 4-dimensional magnetic resonance angiography as a noninvasive procedure to diagnose subclavian steal syndrome in a dog.

CASE DESCRIPTION: A 5-year-old 4.1-kg (9.0-lb) spayed female Toy Poodle was referred because of a 6-month history of sporadic signs of neck pain. CLINICAL FINDINGS: Diagnostic imaging with MRI and CT revealed a dilated radicular artery connecting the right and left vertebral arteries and causing mild compression of the spinal cord. The left subclavian artery caudal to the origin of the left vertebral artery was absent. Subclavian steal syndrome (SSS) was suspected. TREATMENT AND OUTCOME: The owner declined surgical treatment; thus, the dog was treated conservatively with glucocorticoids and analgesics. Eight months later, the dog's clinical signs were unchanged but palliated with the administration of glucocorticoids and analgesics, and 4-dimensional (4-D) magnetic resonance angiography (MRA) revealed that the left vertebral artery received blood supply from the right vertebral artery through the dilated radicular artery and that the left vertebral artery caudal to this site had retrograde flow and drained into the left subclavian artery, confirming the diagnosis of SSS. The owner again declined surgery, and conservative treatment continued. The dog's condition was unchanged at the last follow-up communication 11 months after 4-D MRA. CLINICAL RELEVANCE: Subclavian steal syndrome is an extremely rare condition in dogs, and our findings suggested that 4-D MRA could be used to definitively diagnose SSS in dogs.

Endovascular management of subclavian-steal syndrome in a patient with post-traumatic dissection of an aberrant right subclavian artery.

BACKGROUND: An aberrant right subclavian artery is the most common congenital anomaly of the aortic arch and may cause symptoms due to aneurysmal dilatation, stenosis or occlusion. We present a case of subclavian-steal syndrome due to post-traumatic dissection of an aberrant right subclavian artery. METHODS AND RESULTS: A 50 year-old man presented with dizziness and fainting episodes after exercising his right arm and a systolic blood pressure gradient of 40 mm Hg between the 2 arms. Suspecting a subclavian steal syndrome, a computed tomography angiography was requested which revealed an aberrant right subclavian artery with a severe stenosis proximal to the ostium of the vertebral artery. Transfemoral digital subtraction angiography showed a local dissection of the aberrant right subclavian artery with late retrograde filling of the ipsilateral vertebral artery. The lesion was successfully treated with primary stent implantation (9 mm x 40 mm, LIFESTAR, BARD). On interrogation, the patient recalled an injury to the right arm after falling off a ladder 10 years earlier, as a possible post-traumatic cause for the dissection. He had an uneventful outcome and is symptom-free 12 months down the line. CONCLUSIONS: The combination of post-traumatic dissection of an aberrant right subclavian artery resulting to subclavian steal syndrome is an extremely rare scenario. Endovascular management is a safe, minimally invasive alternative to open surgery.

Endovascular Treatment in the Subclavian Steal Syndrome: Series of 29 Patients

Subclavian steal syndrome is a group of symptoms resulting fromretrograde flow in the vertebral artery, "stealing" blood from the posterior intracranial circulation and other territories, caused by stenosis or occlusion of the subclavian artery proximal to the origin of the same vertebral artery, or even of the brachiocephalic trunk. Most of the time, it is an incidental finding in patients with other conditions or cerebrovascular risk factors. We report a series of 29 patients with an angiographic diagnosis, in which 7 received treatment (all endovascular), all with symptoms directly related to this condition. Advanced age, systemic arterial hypertension, diabetes mellitus, smoking and stroke were comorbidities frequently related. Six patients improved completely after the procedure and one remained with vertigo.

Coronary subclavian steal syndrome causing myocardial Infarction.

Coronary subclavian steal syndrome (CSSS) is a rare complication of the internal mammary artery (IMA) grafting in coronary artery bypass surgery. The technical definition is myocardial ischemia due to the reduced flow of blood, or flow reversal in the IMA graft. This in most cases results from hemodynamically significant proximal subclavian artery stenosis. The clinical presentation is variable and ranges from unstable angina to myocardial infarction, and in some cases, sudden cardiac arrest. CSSS is an entity that is hard to diagnose if one is not actively looking for it. The clinical diagnosis is often complicated, and the prevalence of the disorder is frequently underestimated. In this case presentation, we report a case of myocardial infarction that resulted from significant proximal subclavian artery stenosis.

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.

Don't Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome.

Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.

Contemporary Surgical Management of Aberrant Right Subclavian Arteries (Arteria Lusoria).

BACKGROUND: An aberrant right subclavian artery (ARSA) is in most cases an asymptomatic aortic arch anomaly. However, dysphagia, aneurysm formation (ARSAA), associated Kommerell diverticulum, or cerebellar/arm malperfusion may require invasive therapy. Large-scale clinical trials do not exist in current literature. We report our patient's outcome of a single-center experience and delineate indications for treatment and surgical techniques. METHODS: A single-center retrospective study was conducted between January 1, 2012 through March 1, 2018. Symptomatic or asymptomatic patients with ARSAA who received invasive treatment at the Department for Vascular and Endovascular Surgery, University Hospital Dusseldorf, Germany were included. RESULTS: Eight patients (4 men, 63 ± 14 (39-78) years) were treated with single-stage (n = 4) or multistage (n = 4) procedures. Treatment for ARSAA (n = 4) included ARSA revascularization (subclavian-carotid transposition (SCT) = 3; carotid-subclavian bypass (CSB) = 1), aortic arch debranching (left SCT = 2, bilateral aorto-carotid bypass + left CSB = 1, right-to-left CSB + left-carotid-to-bypass transposition = 1), and thoracic endovascular aortic repair (TEVAR; n = 4). Other strategies included SCT for dysphagia (n = 2) or subclavian steal syndrome (n = 1) and balloon angioplasty for arm claudication (n = 1). Complications involved vascular access (n = 2) and each one partial common carotid artery overstenting without stroke during TEVAR and Horner syndrome after SCT. Mean follow-up was 23 ± 26 (9-67) months. After 7 months, 1 patient required vertebral artery coiling due to type II endoleak with ARSAA progression. Overall mortality was 0%. Technical and clinical success rates were 100%. CONCLUSIONS: Surgical concepts for ARSA aim on preventing aneurysm rupture and alleviate dysphagia or ischemic symptoms. To generate satisfying patient outcomes, individualized therapy planning in specialized centers is vital.