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.

Relationship of inter-arm systolic blood pressure difference with subclavian artery stenosis and vertebral artery stenosis in patients undergoing carotid endarterectomy

Abstract Introduction: The aim of this study was to examine the association of inter-arm systolic blood pressure difference (IASBPD) with carotid artery stenosis, subclavian artery stenosis and vertebral artery stenosis in patients who underwent carotid endarterectomy. Methods: A total of 141 patients (29 females, 112 males; mean age 71.2±10.4 years; range 47 to 92 years) who underwent carotid endarterectomy between September 2010 and December 2017 were retrospectively evaluated. We classified patients into four groups according to the IASBPD ˂ 10 mmHg, ≥ 10 mm Hg, ≥ 20 mmHg and ≥ 30 mmHg. The stenosis of both subclavian and vertebral arteries was considered as ≥ 50%. Results: Of the 141 patients, 44 (31.2%) had ≥ 10 mmHg, 29 (20.5%) had ≥ 20 mmHg and 4 (2.8%) had ≥ 30 mmHg of IASBPD. 26 patients (18.4%) were diagnosed with significant subclavian artery stenosis and 18 (69.2%) of them had more than 20 mmHg of IASBPD. Of the 29 patients with IASBPD ≥ 20 mmHg, 19 patients (65.5%) had a significant subclavian artery stenosis. We found a significant correlation between preoperative symptoms and subclavian artery stenosis (P=0.018) and overall perioperative stroke was seen more frequently in patients with subclavian artery stenosis (P=0.041). A significant positive correlation was observed between vertebral artery stenosis and subclavian artery stenosis (P=0.01). Conclusion: Patients who were diagnosed with both subclavian artery stenosis and IASBPD (≥ 20 mmHg) had a higher risk of postoperative stroke and death, had higher total cholesterol, LDL-C, blood creatinine level, and were more symptomatic.

O significado de uma diferença elevada na pressão arterial entre os dois braços e antes dos implantes dentários: um alerta preocupante, reflexões e tratamento / The significance of intearm arterial blood pressure high difference before dental implant placement: shocking alert, lessons, and case management

Este relato de caso mostra os perigos que uma diferença significativa assintomática na pressão arterial pode trazer à Implantodontia. Paciente do sexo feminino com 75 anos de idade, com perdas de elementos dentais na região posterior de maxila, recebeu como plano de tratamento cirurgias de enxertia e posterior instalação de implantes. Exames pré-operatórios e avaliação cardiológica foram requisitados, sendo autorizadas as cirurgias. Dois atos cirúrgicos foram realizados sem intercorrências. Na terceira cirurgia, no pré-operatório, constatou-se uma diferença de pressão arterial entre os braços direito e esquerdo quando optou-se pelo cancelamento da cirurgia e novo encaminhamento com urgência ao cardiologista em posse do relatório clínico. A pressão arterial mais baixa no braço esquerdo era causada por uma estenose na artéria subclávia com risco aumentado para acidentes vasculares e morbidade cardíaca. Uma angioplastia foi realizada com a instalação de stent, medicações anti-hipertensivas foram mantidas e um antiagregante plaquetário foi introduzido. A paciente foi liberada para continuidade de seu tratamento, com orientações do cardiologista e cirurgião vascular a serem seguidas. Diante do ocorrido e das observações apontadas na literatura pesquisada, pôde-se concluir que o cirurgião terá um melhor panorama das condições físicas dos pacientes se na anamnese ele tomar como rotina a correta aferição da pressão arterial nos dois braços e, diante de qualquer anormalidade, fazer os encaminhamentos necessários para sua segurança e de seus pacientes.

This case report demonstrates how a significant difference at the interarm blood pressure can bring risks to implant dentistry. A 75 years-old female patient with loss of posterior maxillary teeth received a treatment planning grafting surgeries and further implant placement. The pre-operative exams and a cardiologic evaluation were requested, and dental surgeries authorized. The first two separate operations were made without complications. However, in the third surgical appointment, a high difference in blood pressure was detected between the left and right arms. In this way, the surgery was cancelled and the patient urgently referred to the physician. The medical report demonstrated low blood pressure at the left arm caused by the subclavian steal syndrome with risk of vascular accident and cardiac morbidity. An angioplasty was made and a stent was placed, in addition to antihypertensive medications. A platelet anticoagulant was introduced. The patient was released for dental procedures under guidance of the cardiologist and the vascular surgeon. It can be concluded that routine check of blood pressure in both arms can better screen the patient's physical condition and to improve necessary referrals for the patient's safety.

Arteritis de Takayasu: informe de un caso con compromiso supraaórtico y tratamiento quirúrgico / Takayasu's arteritis: report of a case with supraaortic compromise and surgical treatment

La arteritis de Takayasu es una vasculitis inflamatoria crónica de grandes vasos. Fue descrita por primera vez por el oftalmólogo japonés Nikito Takayasu, en el año 1908. Presentamos un caso de arteritis de Takayasu, diagnosticada clínicamente de acuerdo a los criterios del American College of Rheumatology de 1990. Se trata de una paciente de 23 años que ingresa al Hospital Regional de Talca por un accidente vascular encefálico hemisférico y sintomatología de robo subclavio. Se realiza un angio TAC que muestra compromiso severo (oclusión total) del tercio medio y distal del tronco braquiocefálico, carótida común derecha e inicio de la subclavia derecha. Además, este examen demuestra un flujo retrógrado en la arteria vertebral derecha, compatible con el síndrome de robo subclavio. Se decide corregir la oclusión subclavia mediante angioplastía, sin éxito tanto en el abordaje anterogrado como retrógrado. Finalmente se opta por un bypass protésico (politetrafluoroetileno expandido) desde la carótida común izquierda a la subclavia derecha a través de un túnel subcutáneo en la cara anterior del cuello.

Takayasu's arteritis is a chronic inflammatory vasculitis of large vessels. It was first identified by Japanese ophthalmologist Nikito Takayasu, in 1908. A case of Takayasu's arteritis is presented, clinically diagnosed according to the criteria of the American College of Rheumatology of 1990. This is a 23 year oíd patient, entering Talca's Regional Hospital for a stroke, also presenting symptoms of subclavian steal. An angio CT was made, showing severe commitment (total occlusion) in the middle and distal third of the brachiocephalic trunk, right common carotid and the beginning of right subclavian artery. In addition, this test shows retrograde flow on the right vertebral artery, compatible with the subclavian steal syndrome. It was decided to correct the subclavian occiusion through angioplasty, without success, in both the anterograde and retrograde approach; finally opting for a prosthetic bypass (expanded polytetrafluoroethylene) from left common carotid to right subclavian artery through a tunnel of the subcutaneous front of the neck.

Intermittent infusion of inotropes in the outpatients setting: one-year post treatment analysis

The course of patients with New York Heart Association (NYHA) class III and IV and refractory heart failure symptoms is characterized by progressive clinical deterioration and frequent hospital readmissions. The value of intermittent intravenous administration of inotropes in managing this group of patients in the outpatient setting has been controversial. In this study, patients with refractory heart failure symptoms were enrolled to assess the impact of a multidisciplinary outpatient program in terms of on hospital admissions, emergency room visits, and interval free of symptoms after administration of inotropes. This is a retrospective analysis on 41 patients with refractory heartfailure treated at our outpatient cardiac infusion unit over a 20 month period. Thirteen patients with a NYHA class III [age 64 +/- 13; LVEF 27 +/- 9 percent] and 28 patients with a NYHA class IV [age 65 +/- 13 years; LVEF 21 +/- 9 percent], mostly males, were included. A total of 65 admissions for decompensated HF were recorded in the previous 6-months prior to initiation of the outpatient program; compared to only 4 emergency room visits and 7 hospital admissions after enrollment. Furthermore, 17 patients have been discharged with improvement in NYHA class from 3.5 +/ 0.6 to 1.4 +/- 0.5. On these patients, the interval free of symptoms since the last infusion treatment has ranged from 201 to 489 days, without emergency room visits or hospital admissions for congestive heart failure. The results of this study support the use of intermittent infusion of inotropes in the outpatient setting. Although the natural history for patients with refractory heart failure has been grim; the use of these intermittent infusions may in fact alter the natural course of end stage congestive heart failure patients and deserves further investigation.

Cirurgia reconstrutiva e angioplastia no tratamento de nove doentes portadores de oclusöes crônicas das artérias subclávias / Reconstrutive surgery and percutaneous angioplasty in the tratment of nine patients with chronic subclavian artery occlusion

A proposta deste estudo foi apresentar uma série de pacientes com doença oclusiva da artéria subclávia tratados por procedimento cirúrgico ou angioplastia. Durante um período de cinco anos, nove pacientes com idade média de 54 anos foram submetidos a seis derivaçöes carótidas-subclávias, uma endarterectomia e duas angioplastias. Os resultados clínicos foram inteiramente satisfatórios em quatro pacientes com sintomas cerebrais, em dois com isquemia de membro e em dois dos três com sintomas mistos. Um paciente faleceu e dois foram perdidos para seguimento. As reconstruçöes permaneceram pérvicas em cinco pacientes entre 12 e 28 meses de seguimento de seguimento mas ocluiu em outro. A revascularizaçäo das artérias subclávia é efetiva tanto com procedimentos cirúrgicos como com a angioplastia.