Carotid Artery Stenosis after Radiation Therapy in a Patient with Lung Cancer: A Case Report and Literature Review.

We reported a case of carotid artery stenosis with stroke symptoms detected in a patient with lung cancer after radiotherapy. The patient was a 58-year-old male with a complaint of \"a single episode of temporary amaurosis in the right eye for 10 minutes". The clinical diagnosis at admission, after consideration of the patient's age, medical history, and auxiliary examination results, was as follows: lung cancer; right common carotid artery stenosis; left common carotid artery stenosis; left vertebral artery stenosis; and right subclavian artery occlusion with right subclavian steal syndrome (Grade 3). Carotid angioplasty and stenting (CAS) were subsequently performed. During the 6-month follow-up, we observed no episode of temporary vision loss or other signs of stroke. Clinicians should pay great attention to delayed radiation-induced carotid stenosis. It is recommended that patients with a history of radiotherapy should undergo regular color Doppler ultrasound examination of the cervical region to diagnose, prevent, and treat RICS in an expedient fashion. This approach should improve survival rate and quality of life.

Diffusion-weighted Whole-body Imaging with Background Body Signal Suppression (DWIBS) as a Novel Imaging Modality for Disease Activity Assessment in Takayasu's Arteritis.

A 26-year-old woman with Takayasu's arteritis (TAK) experienced back and neck pain during tocilizumab (TCZ) treatment. The levels of C-reactive protein were normal, and ultrasonography revealed no significant changes. Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) showed signal enhancement in the walls of several arteries. Contrast computed tomography showed arterial inflammation in the same lesion. After increasing the dose of prednisolone and TCZ, all signal enhancements decreased and continued to decrease, as observed on days 76 and 132. Thus, DWIBS may be a novel imaging modality for assessing the disease activity of TAK, particularly during follow-up.

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.

A review of subclavian steal syndrome with clinical correlation.

Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.

[Comparative analysis of carotid-subclavian transposition and stenting in case of stenotic damage of subclavian artery].

So carotid-subclavian transposition and stenting are effective and safe methods of correction of occlusive subclavian artery disease. Angioplasty and stenting of the subclavian artery is particularly indicated in patients with high surgical risk. Patients at low risk of surgery is preferred execution carotid-subclavian transposition.

[Supra-aortic trunks occlusive disease: three different treatment approaches]. / Doença oclusiva dos troncos supra-aórticos: Três opções de revascularização.

Unlike carotid bifurcation atherosclerotic stenosis, supra-aortic trunks (SAT) occlusive disease is rare and its revascularization uncommon, accouting for less than 10% of the operations performed on the extracranial brain-irrigating arteries. There are three different treatment approaches: transthoracic, extra-anatomic cervical and endovascular. Endovascular repair is gaining popularity as first-line therapy for proximal lesions with favorable anatomy because of its low morbidity and rare mortality. Extra-anatomic bypass is a safe and durable reconstruction and should be considered in patients with single vessel disease, with cardiopulmonary high-risk or with limited life expectancy. If cardiac surgery is needed, central transthoracic reconstruction is preferable, and the two procedures should be combined. The long-term patency of bypasses with aortic origin, specially when multiple vessels are involved, is superior to other repair techniques. We present three clinical cases that illustrate each of these therapeutic strategies: central brachiocephalic revascularization and synchronous cardiac surgery in a patient with complex SAT atherosclerosis disease; subclavian-carotid transposition for disabling upper limb claudication; and subclavian artery stenting for subclavian-steal syndrome. Surgical approach selection should be based on the individual patient's anatomy and operative risk.

Long-term results of endovascular therapy for proximal subclavian arterial obstructive lesions.

BACKGROUND: Endovascular therapy is a treatment option for localized occlusion of the subclavian artery. In this report the long-term experience with 59 patients is presented. METHODS: Between June 1998 and September 2008, we used endovascular therapy to treat 61 subclavian arterial obstructive lesions in 59 patients (46 males and 13 females, 34 - 82 years of age with a mean age (61.9 + or - 11.0) years). Twenty patients (34%) had clinical symptoms due to vertebrobasilar insufficiency, 26 (44%) had disabling arm ischemia, and 13 (22%) had both symptoms. We performed all procedures under local anesthesia. The approaches were from the femoral artery (n = 47), brachial artery (n = 1, involving bilateral subclavian disease) or both (n = 11). Sixty stents were implanted. All patients were followed-up at 1, 3, 6, and 12 months post-procedure, and annually thereafter. RESULTS: We achieved technical success in 58 (95.1%) arteries, all of which were stented. There were three technical failures; two were due to the inability to cross over an occlusion, necessitating the switch to an axillo-axillary bypass, and the third was due to shock after digital subtraction angiography and prior to stenting. Arterial stenosis pre- and post-stenting was (83.6 + or - 10.8)% and (2.5 + or - 12.5)% (P < 0.01). Clinical success was achieved in 55 of the 59 patients (93.4%). Of the four clinical failures, three were technical and the remaining patient had a stent thrombosis. Systolic blood pressure difference between the two brachial arteries was (44.7 + or - 18.5) vs. (2.2 + or - 3.9) mmHg (P < 0.01). Primary patency was 98% at 12 months, 93% at 24 months, and 82% at 5 years. Five patients were lost to follow-up by 12 months post-stenting. Significant recurrent obstruction developed in five patients with resumption of clinical symptoms. The overall survival rate was 98.2% at 12 months, 89.5% at 24 months, and 84.5% at 5 years. CONCLUSIONS: Endovascular therapy for proximal subclavian arterial obstructive lesions is effective and successful. This minimally invasive treatment may be the first choice of treatment for proximal subclavical arterial obstructive lesions.

Coronary-subclavian steal phenomenon late after coronary artery bypass grafting: an underappreciated cause of myocardial ischemia?

Coronary-subclavian steal (CSS) is an increasingly reported phenomenon after coronary artery bypass graft (CABG) operation and it is caused by proximal subclavian artery stenosis in patients with internal thoracic artery grafts. We discuss briefly the diagnostic strategies to rule out significant subclavian stenosis before CABG and, in the follow-up, the importance of subclinical detection of coronary-subclavian steal before the potential onset of myocardial ischemia. Although the most appropriate management of concomitant brachiocephalic and coronary artery disease remains a matter of debate, patients developing CSS syndrome after CABG can be treated successfully by both surgical and percutaneous techniques. Retrospective analysis of surgical databases will help to identify the predictors, if any, of subclavian artery disease progression in candidates for internal thoracic artery grafting, in order to choose a tailored surgical approach.

Coronary-subclavian steal syndrome presenting with ventricular tachycardia.

Coronary-subclavian steal through the left internal mammary graft is a rare cause of myocardial ischemia in patients who have had a coronary bypass surgery. We report a 70-year-old man who presented with sustained monomorphic ventricular tachycardia 5 years after the surgical creation of a left internal mammary to the left anterior descending artery. Cardiac catheterization illustrated that the left subclavian artery was occluded proximally and that the distal course was visualized by retrograde filling through the left internal mammary graft. Clinical ventricular tachycardia was reproducibly induced with a single ventricular extrastimulus, and antitachycardia pacing terminated the tachycardia. Restoration of blood flow by way of a Dacron graft placed between the descending aorta and the subclavian artery resulted in the total relief of symptoms. Ventricular tachycardia could not be induced during the control electrophysiologic study after surgical revascularization.

Variant of subclavian steal in the setting of ipsilateral common carotid artery occlusion: case report.

Subclavian steal is a well-described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.

Endovascular management versus surgery for proximal subclavian artery lesions.

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Acute basilar artery occlusion in a patient with left subclavian artery occlusion due to first rib anomaly: case report.

A previously healthy 22-year-old man presented with thoracic outlet syndrome manifesting as Raynaud's phenomenon in the left hand and embolic occlusion of the basilar artery. Three-dimensional computed tomography angiography showed that the left subclavian artery was occluded as it passed over the abnormal first rib. Retrograde propagation of the thrombus from the site of arterial occlusion and/or reflux of embolic material was suspected. Medical therapy was started. The patient underwent resection of the anomalous rib. Postoperative angiography demonstrated that the subclavian artery was recanalized with almost normal distal flow. The basilar artery was also recanalized. Thoracic outlet syndrome due to a first rib anomaly may cause stroke.

Intrathoracic carotid bifurcation in Klippel-Feil syndrome.

Intrathoracic carotid bifurcation is rare with only five other cases reported. This anatomic variant with posteromedial origin of the internal carotid artery (ICA) appears to be part of the Klippel-Feil syndrome, a rare congenital defect characterized by fusion of the cervical vertebrae. Caution is advised when planning thoracic and cervical vascular procedures. Angiography carries higher risk of unintentional ICA catheterization due to the short common carotid artery length. The intrathoracic location of the carotid bifurcation makes endarterectomy difficult and patients may do better with carotid artery stenting. Ultrasound can be confusing in these patients and MRA may be preferable.

A new form of coronary subclavian steal syndrome: 'the spinning wheels' syndrome.

Coronary subclavian steal syndrome refers to decreased or reversed internal mammary artery flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft. We report a case, the first in the literature, of a right internal mammary artery-coronary-subclavian unidirectional steal syndrome. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.