Carotid Subclavian Bypass for the Treatment of Coronary Subclavian Steal Syndrome

Abstract 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.

A case of subclavian steal syndrome

Subclavian steal syndrome is a relatively rare condition that results from occlusion of the subclavian artery proximal to the origin of the vertebral artery. This causes a reversal in the direction of the blood flow in the vertebral artery, leading to symptoms of vertebrobasilar insufficiency. In this article, we report a case of subclavian steal syndrome in a 55 year old male, who presented with giddiness, and variation in blood pressures in both upper limbs, was investigated with doppler and MR angiography. This article emphasises physical examination with discrepancy in pulse and blood pressure should bring attention to diagnosis of this syndrome.

Oculo-auriculo-vertebral spectrum associated with aberrant subclavian artery in an infant with recurrent respiratory distress / Espectro oculoauriculovertebral associado à artéria subclávia aberrante em lactente com desconforto respiratório recorrente

ABSTRACT Objective: To describe an infant with craniofacial microsomia and recurrent respiratory distress associated with aberrant right subclavian artery in order to review its most frequent congenital anomalies and alert the pediatrician to its rarer and more severe complications. Case description: This case report involves an 18-month-old male infant, only son of non-consanguineous parents. At birth, the child presented craniofacial dysmorphisms (facial asymmetry, maxillary and mandibular hypoplasia, macrostomia, grade 3 microtia, and accessory preauricular tag) restricted to the right side of the face. Additional tests showed asymmetric hypoplasia of facial structures and thoracic hemivertebrae. No cytogenetic or cytogenomic abnormalities were identified. The patient progressed to several episodes of respiratory distress, stridor, and nausea, even after undergoing gastrostomy and tracheostomy in the neonatal period. Investigation guided by respiratory symptoms identified compression of the esophagus and trachea by an aberrant right subclavian artery. After surgical correction of this anomaly, the infant has not presented respiratory symptoms and remains under multidisciplinary follow-up, seeking rehabilitation. Comments: Craniofacial microsomia presents a wide phenotypic variability compared to both craniofacial and extracraniofacial malformations. The latter, similarly to the aberrant right subclavian artery, is rarer and associated with morbidity and mortality. The main contribution of this case report was the identification of a rare anomaly, integrating a set of malformations of a relatively common condition, responsible for a very frequent complaint in pediatric care.

RESUMO Objetivo: Descrever lactente com microssomia craniofacial e desconforto respiratório recorrente associado à artéria subclávia direita aberrante, com o intuito de revisar as anomalias congênitas mais frequentes e alertar o pediatra sobre suas complicações mais raras e de maior gravidade. Descrição do caso: Lactente do sexo masculino, 18 meses de idade e filho único de casal não consanguíneo. Ao nascimento, foram observadas dismorfias craniofaciais (assimetria facial, hipoplasia maxilar e mandibular, macrostomia, microtia grau 3 e apêndice na linha trago-oral) restritas ao lado direito da face. Os exames complementares evidenciaram hipoplasia assimétrica da face e hemivértebras torácicas. Não foram identificadas anormalidades citogenéticas ou citogenômicas. O paciente evoluiu com diversos episódios de desconforto respiratório, estridor e náuseas, mesmo tendo realizado gastrostomia e traqueostomia no período neonatal. A investigação direcionada para os sintomas respiratórios identificou a compressão de esôfago e traqueia por uma artéria subclávia direita aberrante. Após a correção cirúrgica dessa anomalia, o lactente não tem apresentado sintomas respiratórios e mantém seguimento multidisciplinar buscando reabilitação. Comentários: A microssomia craniofacial apresenta grande heterogeneidade fenotípica em relação às malformações tanto craniofaciais como extracraniofaciais. Estas últimas, como a artéria subclávia direita aberrante, são mais raras e associadas à morbimortalidade. A principal contribuição deste relato de caso foi o reconhecimento de uma anomalia rara, integrando um conjunto de malformações de uma condição relativamente comum e sendo responsável por uma queixa muito frequente no atendimento pediátrico.

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.

Application of subclavian-carotid transposition to patients with proximal subclavian artery occlusion unable to be intervened / 中国胸心血管外科临床杂志

@#Objective    To investigate the efficacy of subclavian-carotid transposition (SCT) in treating patients with proximal subclavian artery occlusive diseases who were unable to be intervened, such as failure of intervention, congenital malformation and unwillingness to intervention. Methods    A retrospective review of 19 patients with proximal subclavian artery occlusion who underwent SCT from May 2016 to December 2018 was done. There were 14 males and 5 females with an average age of 54.05±17.34 years. The advantages and disadvantages of SCT in the treatment of proximal subclavian artery occlusion were analyzed. Results    All patients achieved immediate remission of symptoms after surgery. The stenosis degree of the proximal subclavian artery decreased from 100.0%±0.0% to 12.7%±10.1% after surgery. The average blood pressure difference between the unaffected side and the affected side decreased from 11.95±10.60 mm Hg to 0.89±5.75 mm Hg (P<0.01). Peripheral nerve injury occurred in 7 (36.8%) patients. The in-patient cost of subclavian artery occlusion patients who received subclavian artery interventional therapy in our hospital during the corresponding period was 3 392.12 yuan higher than that of the SCT group in average (if eliminating the patients whose cost was far from the average value, the cost of interventional therapy was 4 812.01 yuan higher than that of the SCT group in average). During 1-3 years' follow-up, 6 patients with neurological complication relieved. One- and three-year patency rates were 100.0%. No perioperative stroke, death or re-operation happened. Conclusion    SCT is an ideal process for the patients with subclavian artery occlusion who cannot accept subclavian artery interventional therapy.

Controle de danos para lesão de artéria subclávia / Damage control for subclavian artery injury

Resumo Os traumas penetrantes de vasos subclávios atingem mortalidade de até 60% em um cenário pré-hospitalar. A mortalidade no intraoperatório varia de 5-30%. Apresenta-se um caso de estratégia de controle de danos para um paciente com lesão na origem da artéria subclávia esquerda, através de ligadura, sem necessidade de outra intervenção, mantendo a viabilidade do membro superior esquerdo por meio de circulação colateral. Os autores fazem uma revisão sobre vias de acesso e estratégias de tratamento com ênfase em controle de danos para lesões de vasos subclávios.

Abstract 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.

Isquemia miocárdica secundaria a fenómeno de robo de flujo por fístulas coronarias: reporte de caso / Myocardial ischemia secondary to flow steal phenomenon by coronary fistulas: case report / Isquemia miocárdica secundária ao fenômeno de roubo de fluxo por fistulas coronárianas: relato de caso

Resumen: Las fístulas coronarias son una comunicación anómala directa entre las arterias coronarias y las cavidades cardíacas o alguno de los vasos sanguíneos próximos al corazón. Son poco comunes, con una incidencia angiográfica entre 0,1%-2%. Dependiendo de la magnitud de robo coronario, pueden ser asintomáticas o causar cuadros clínicos graves con alta repercusión funcional, como isquemia miocárdica, insuficiencia cardíaca congestiva, endocarditis, infecciones recurrentes del aparato respiratorio o en casos raros hipertensión pulmonar. Se presenta el caso de una paciente con fístulas coronarias que ocasionaron isquemia miocárdica por robo de flujo coronario con importante repercusión clínica y hemodinámica. El diagnóstico definitivo se llevó a cabo mediante intervencionismo coronario percutáneo y dadas las características anatómicas de las fístulas, se determinó tratamiento médico.

Summary: Coronary fistulas are an anomalous direct communication between the coronary arteries and one of the four cardiac cavities or one of the blood vessels near the heart, are uncommon with an angiographic incidence between 0.1% - 2%, and, depending of the magnitude of coronary steal, they may be asymptomatic or cause severe clinical symptoms with high functional repercussion, such as myocardial ischemia, congestive heart failure, endocarditis, recurrent respiratory infections or, in rare cases, pulmonary hypertension. We present a case of a female patient with coronary fistulas that caused myocardial ischemia due to coronary flow steal with important clinical and hemodynamic repercussions. The definitive diagnosis was made through percutaneous coronary intervention and given the anatomical characteristics of the fistulas, medical treatment was determined.

Resumo: As fístulas coronarianas são uma comunicação anômala direta entre as artérias coronárias e uma das quatro cavidades cardíacas ou um dos vasos sanguíneos próximos ao coração; são incomuns com uma incidência angiográfica entre 0,1% - 2% e, dependendo da magnitude do roubo coronariano, podem ser assintomáticos ou causar sintomas clínicos graves, com alta repercussão funcional, como isquemia miocárdica, insuficiência cardíaca congestiva, endocardite, infecções respiratórias de repetição ou, em raros casos, hipertensão pulmonar. Apresentamos um caso de uma paciente com fístulas coronarianas que causaram isquemia miocárdica por roubo de fluxo coronariano com importante repercussão clínica e hemodinâmica. O diagnóstico definitivo foi feito por meio de intervenção coronariana percutânea e, dadas as características anatômicas das fístulas, foi determinado tratamento médico.

Endovascular Treatment in the Subclavian Steal Syndrome

When the proximal occlusion or stenosis of the subclavian or of the brachiocephalic artery may require distal arterial filling through reversal flow from the vertebral artery, causing clinically significant blood supply reduction to the brainstem, it is called subclavian steal syndrome (SSS). We report a 54-year-old male patient who presented with multiple episodes of syncopes and vascular claudication due to right SSS. He underwent an angioplasty, evolving with complete improvement of the symptoms. We review the clinical presentation, the diagnosticmethods, and the treatment options of the disease.

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.

Repeated Expansion of Cerebral Infarction Accompanied by Takayasu's Arteritis and Subclavian Steal Syndrome Causes Difficulty in Rehabilitation：A Case Report / The Japanese Journal of Rehabilitation Medicine

The incidence of cerebral infarction due to Takayasu's arteritis is relatively low, and there are few reports on rehabilitation for this condition. We report the case of a patient with Takayasu's arteritis, repeated expansion of cerebral infarction, and subclavian steal syndrome who required careful observation at the start of ambulation. A 17-year-old male was diagnosed with Takayasu's arteritis complicated by subclavian steal syndrome eleven months ago. He was admitted for the treatment of cerebral infarction in the right side of the middle cerebral artery. One day after admission, the area of the infarction expanded. Next day, after he started ambulation (16 days after admission), the area of the infarction further expanded despite ongoing medical treatments, including corticosteroid and immunosuppressant administration. Cerebral blood flow scintigraphy showed stenosis of right middle cerebral, right internal carotid, right common carotid, brachiocephalic, left subclavian, and left vertebral arteries.These arterial stenosis progressed in the two weeks following admission. Thereafter, he complained of dimmed vision more frequently when he raised his body to an upright position. The rehabilitation schedule had to be carefully adjusted according to his symptoms. Two and a half months later, angiographic examination showed development of adequate collateral circulation from the bilateral intercostal arteries to both vertebral arteries. After we confirmed the collateral circulation, we allowed him to use a wheelchair. The confirmation of collateral circulation by image analysis is important in order to decide the time to start ambulation in patients with Takayasu's arteritis (early phase) along with repeated cerebral ischemia.

Repeated Expansion of Cerebral Infarction Accompanied by Takayasu's Arteritis and Subclavian Steal Syndrome Causes Difficulty in Rehabilitation：A Case Report / The Japanese Journal of Rehabilitation Medicine

The incidence of cerebral infarction due to Takayasu's arteritis is relatively low, and there are few reports on rehabilitation for this condition. We report the case of a patient with Takayasu's arteritis, repeated expansion of cerebral infarction, and subclavian steal syndrome who required careful observation at the start of ambulation. A 17-year-old male was diagnosed with Takayasu's arteritis complicated by subclavian steal syndrome eleven months ago. He was admitted for the treatment of cerebral infarction in the right side of the middle cerebral artery. One day after admission, the area of the infarction expanded. Next day, after he started ambulation (16 days after admission), the area of the infarction further expanded despite ongoing medical treatments, including corticosteroid and immunosuppressant administration. Cerebral blood flow scintigraphy showed stenosis of right middle cerebral, right internal carotid, right common carotid, brachiocephalic, left subclavian, and left vertebral arteries.These arterial stenosis progressed in the two weeks following admission. Thereafter, he complained of dimmed vision more frequently when he raised his body to an upright position. The rehabilitation schedule had to be carefully adjusted according to his symptoms. Two and a half months later, angiographic examination showed development of adequate collateral circulation from the bilateral intercostal arteries to both vertebral arteries. After we confirmed the collateral circulation, we allowed him to use a wheelchair. The confirmation of collateral circulation by image analysis is important in order to decide the time to start ambulation in patients with Takayasu's arteritis (early phase) along with repeated cerebral ischemia.

Lateral costal artery: clinical importance of an accessory thoracic artery

Abstract The lateral costal artery has sometimes been identified as the culprit for the "steal phenomenon" after coronary artery bypass grafting, besides being occasionally used for myocardial revascularization. Its branches make anastomoses with the internal thoracic artery through lateral intercostal arteries. We aim to report, on three cases, the clinical significance of a well-developed lateral costal artery after coronary artery bypass grafting. Two out of three patients who underwent coronary artery bypass graft surgery in our center between June 2010 and August 2017, applied to us with stable angina pectoris, while the third one was diagnosed with acute coronary syndrome after applying to the emergency department. In coronary cineangiography, in all three cases, a well-developed accessory vessel arising from the proximal 2.5 cm segment of the left internal thoracic artery coursed as far as the 6th rib was detected, and it was confirmed to be the lateral costal artery. A stable angina pectoris in two of the patients was thought to be the result of steal phenomenon caused by the well-developed lateral costal artery. In the two cases with stable angina pectoris the lateral costal artery was obliterated via coil embolization. In the other case with the proximal left anterior descending artery stenosis, before percutaneous coronary intervention, the lateral costal artery was obliterated via coil embolization and the occluded subclavian artery was stented. Routine visualization in cineangiography and satisfactory surgical exploration of the left internal thoracic artery could be very helpful to identify any possible accessory branch of the left internal thoracic artery like the lateral costal artery.

Subclavian artery stenosis combined with vertebral artery stenosis may lead to compensatory blood flow changes in the contralateral vertebral artery / 南方医科大学学报

OBJECTIVE@#To investigate the severity of blood steal and the hemodynamic profiles in patients with subclavian artery stenosis combined with vertebral artery stenosis.@*METHODS@#A retrospective analysis was performed of transcranial Doppler (TCD) data from patients with subclavian artery stenosis (SAS) and concomitant unilateral/bilateral vertebral artery stenosis (VAS, >50%) or occlusion in our institution between February, 2014 and July, 2018.Thirty-seven patients with SAS combined with VAS (SAS+VAS) were reviewed for types of blood steal, peak systolic velocities of blood flow in affected subclavian artery and the contralateral vertebral artery, and the findings of hyperemia testing.These data were also reviewed for 39 SAS patients without VAS (control group) for comparison of blood steal and hemodynamic profiles.@*RESULTS@#In SAS+VAS group, 5 patients showed no blood steal; blood steal in stage Ⅰ was found in 22 patients, stage Ⅱ in 7, and stage Ⅲ in 3, as compared to the numbers of 17, 12 and 10 in the control group, respectively (H=9.431, =0.002).The peak systolic velocity of the contralateral vertebral artery was 43.91±17.43 cm/s in SAS+VAS group, significantly lower than that in the control group (53.56±17.45 cm/s; = 629.5, =0.006).Hyperemia testing showed a significant difference in the negative rate between SAS+VAS group and the control group[35.1%(13/37) 7.7%(3/39);=8.603, =0.003).@*CONCLUSIONS@#SAS combined with VAS may lead to reduced compensatory blood flow in the contralateral vertebral artery to lessen the severity of subclavian steal syndrome.

The clinical research on the screening,diagnosis and treatment of the left subclavian artery stenosis before the coronary artery bypass grafting / 天津医药

Objective To discuss the meanings and methods of the screening, diagnosis and treatment of the left subclavian artery stenosis before the coronary artery bypass grafting (CABG). Methods A total of 612 patients intend to perform coronary artery bypass grafting in Tianjin Thoracic Hospital,and who were with severe stenosis or occlusion with left subclavian artery were screened by non invasive arteriosclerosis before operation. The diagnosis was confirmed by computerized tomography angiography(CTA),then the stenting angioplasty to the left subclavian artery was performed.The off-pump bypass surgery with the left internal thoracic artery(LITA)-left anterior descending artery (LAD) bypass was performed one week after operation.Results The CTA and digital subtraction angiography(DSA)confirmed the results of the left subclavian stenosis according to the non-invasive artery testing.All the 5 patients were performed with the stenting angioplasty to the left subclavian artery successfully,and the residual stenosis rate was<10%.The clinical symptoms were markedly improved after operations in all symptomatic patients,and the systolic pressure difference was<20 mmHg in two upper extremities.The blood flow was enough in LITA during the LITA-LAD bypass.The angina pectoris was improved after the operation. No coronary-subclavian artery steal phenomenon occurred. Neither stroke, myocardial infraction nor death occurred during perioperative period.All the patients were followed up for a time of 6-12 months,and the average time was about 10 months.No posterior circulation,upper limbs or myocardial ischemia occurred,and the systolic pressure difference was<20 mmHg in two upper extremities.Conclusion The non-invasion testing is of unique value in the screening of the left subclavian artery stenosis.

A retrospective study on the different methods of interventional therapy for splenic artery steal syndrome after liver transplantation / 中华肝胆外科杂志

Objective To study the use of contrast-enhanced ultrasound in diagnosing splenic arterial steal syndrome (SASS) after liver transplantation,and to compare the curative effect,safety and follow-up results of the different embolization methods in the treatment of SASS after liver transplantation.Methods From January 2005 to December 2017,41 patients after liver transplantation in our hospital developed splenic artery steal syndrome and were treated with splenic arterial embolization.All these patients underwent ultrasound,and in 19 patients contrast-enhanced ultrasonography was also done to detect the presence of splenic artery steal.The findings were confirmed by angiography.These patients then underwent splenic arterial embolization.In 32 patients coil embolization was done (group A) and in 9 patients embolization was assisted with Amplatzer occluders (group B).Results In all the 41 patients with SASS,angiography after splenic artery embolization showed the second and third order arterial branches in the liver increased in number and in diameter with good blood flow compared with those before treatment.The postoperative blood flow and pattern on ultrasound returned to normal.In group A,12 patients (12/32,37.5％) developed splenic infarction,including 11 patients with partial splenic infarction,and 1 patient developed a splenic abscess after complete splenic infarction.In group B,two patients developed partial splenic infarction (2/9,22.2％).All the patients with splenic infarct had no clinical symptoms.No treatment was required except for the patient who developed splenic abscess after complete splenic infarction.The patient recovered well after treatment with antibiotics and splenic abscess drainage.There was no other complications.Conclusions Contrast-enhanced ultrasound provided early diagnosis of splenic artery steal after liver transplantation.Interventional splenic artery embolization was safe and effective to treat splenic arterial steal syndrome after liver transplantation.Coil embolization assisted with Amplatzer occluders was better than the traditional coil embolization with more accurate embolization site and fewer complications.

Síndrome coronariana aguda como apresentação atípica do fenômeno de roubo subclávio / Acute coronary syndrome as an atypical presentation of the phenomenon of subclavian steal

Roubo coronariano da subclávia (RCS) é um fenômeno raro que ocorre em pacientes submetidos a cirurgia de revascularização miocárdica com enxerto de artéria torácica interna esquerda (ATIE) e que causa estenose da artéria subclávia ipsilateral e proximal à origem da ATIE. Relatamos o caso de um paciente masculino de 65 anos que apresentou quadro atípico de síndrome do RCS, manifestando-se como síndrome coronariana aguda no pós-operatório de cirurgia vascular (AU)

Coronary subclavian steal (CSS) is a rare phenomenon that occurs in patients undergoing coronary artery bypass graft surgery using the left internal thoracic artery (LITA) causing stenosis of the ipsilateral subclavian artery proximal to the origin of the LITA. We report the case of a 65-year-old male patient who presented with atypical CSS syndrome, manifesting as acute coronary syndrome after vascular surgery (AU)

Observation points and nursing for patients with subclavian steal syndrome after stent implantation / 中国实用护理杂志

Objective To sum up the observation points and nursing measures for patients with subclavian steal syndrome after stent implantation,improve the predictive nursing and reduce the occurrence of postoperative complications. Methods Reviewed and summarized the nursing process and experience of 19 cases after stent implantation. Included prevention from complication, discharge guidance,the close observation of vital signs and the changes of disease. Results All 19 patients were cured after stent implantation and no serious complication occurred. Conclusions Endovascular stenting is an effective way for the treatment of subclavian steal syndrome. meticulous nursing and prevention of complications can ensure the success of surgery in the process of treatment .

Subclavian artery steal syndrome patients with interventional therapy / 局解手术学杂志

Objective To explore the feasibility and effect of intervention therapy for patients subclavian steal syndrome.MethodsThe data of 35 patients with subclavian artery steal syndrome in neurology department of our hospital from October 2014 to March 2016 were retrospectively analyzed.All patients treated with pecutaneous transtuminl angioplasty and stenting.The degree of vascular stenosis was measured by digital subtraction angiography, the inter-arm blood pressure was tested by mercury sphygmomanometer.And the clinical manifestations before and after surgery were compared.All patients were followed up for 1 to 12 months,the clinical manifestations,blood flow and vascular stenosis degree in patients were observed.Results All patients were finished pecutaneous transtuminl angioplasty and stenting successfully,7 patients with serious vascular stenosis treated with percutaneous intravascular balloon dilatation at first.The average artery stenosis before operation was(74.73±10.42)%,while it decreased to(8.60+3.16)% after surgery,which were measured by DSA,the difference was significant(P<0.01).The result from mercury sphygmomanometer showed that the inter-arm blood pressure from preoperative(44.43±10.12)mmHg to postoperative (10.09+4.80)mmHg (2~7 days),systolic blood pressure differential minified significantly,the difference was significant(P<0.01).All patients were followed up for 1 to 12 months,support forms of 34 cases were in good conditions without new narrow,1 case appeared narrow in postoperative 7 months,then recovered after reoperation;symptoms of 28 cases significantly improved or disappeared,5 cases partly alleviated,2 cases had recurrence,no serious complications such as thrombosis and severe infarction occurred.Conclusion The pecutaneous transtuminl angioplasty and stenting is stable,high successful and low short-term recurrence rate for subclavian steal syndrome,which is good to alleviate vascular stenosis,reduce interrm blood pressure difference and improve clinical manifestation.

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.

Variations in Origin of Gastroduodenal Artery: A Cadaveric Study.

Background: Gastroduodenal artery (GDA) is usually the first branch of the common hepatic artery from celiac trunk. In patients with chronic pancreatitis visceral artery aneurysms, incidence of up to 10% has been reported. The aneurysms occur most frequently in the splenic artery (10.4%); the common hepatic, gastroduodenal (1.5%), and pancreaticoduodenal arteries are affected. Material and Methods: It was a cross-sectional study conducted in the Department of General Surgery and Forensic Medicine, N.S.C.B. Medical College, Jabalpur during the period from August 2012 to August 2013. Abdomen of the cadaver will be accessed by the standard postmortem midline incision (sternum to pubes). Vascular anatomy of the GDA and vein will be dissected out in-situ using standard surgical instruments. The distance from the pylorus to the GDA will be measured by measuring tape. Results: In our study, out of total 31 cadavers, 19 (61.2%) were of male and 12 (38.8%) were of females. In all the cases, the site of origin of GDA is from the celiac axis of the common hepatic artery. Out of total 19 male cadavers, 17 (89%) showed a distance of 2.5-3 cm between pylorus and GDA and remaining 2 (11%) showed a distance of 3-3.5 cm. Conclusion: In our study, GDA has been seen arising from common hepatic artery from the celiac axis in 100% of cases. Previous studies have also given very less percentage of rare sites of origin but with the advent of newer modalities of investigations such as Doppler studies and computed tomography angiograms this very less percentage of rare variations can be diagnosed if there are knowledge and suspicion. This will help a lot to prevent major catastrophe during surgeries and radiological interventions.