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.

Síndrome do roubo oculto da subclávia direita causado por dissecção aórtica tipo A de Stanford que evoluiu no pós-operatório tardio com suboclusão do tronco braquicefálico / Occult-right subclavian steal syndrome caused by stanford type A aortic dissection that evolved in the late postoperative period with subocclusion of the brachiocephalic trunk

Paciente de 50 anos, sem fatores de risco e/ou desencadeantes conhecidos, apresentou dissecção aórtica tipo A de Stanford. Foi submetido à excisão da valva aórtica nativa, implante de prótese mecânica e reconstrução da raiz da aorta com enxerto orgânico. Três meses após cirurgia, estando totalmente assintomático, foi submetido, em nosso serviço, à ecografia vascular, com Doppler colorido, das carótidas e vertebrais que mostrou fluxo em artéria vertebral direita com padrão de desaceleração mediossistólica (roubo oculto da subclávia direita), também chamado Sinal do Coelho. A angiotomografia mostrou tronco braquiocefálico com lâmina de dissecção em toda a sua extensão, artéria subclávia direita com lâmina de dissecção em seu terço proximal, artéria carótida comum direita com lâmina de dissecção visualizada em seu terço proximal, artéria vertebral direita com origem na artéria subclávia direita (na sua porção sem dissecção). Em face do estado clínico do paciente, foi adotada observação clínica, com acompanhamento angiotomográfico e ecográfico dos vasos cervicais, semestralmente.

A 50-year old patient with an aortic dissection (Stanford type A) with no previous risk factors. Excision of the native valve and implantation of mechanical aortic prosthesis were made. Also, carried out reconstruction of the aortic root with organic graft. Postoperatively, the patient came to our department after three months totally asymptomatic and the color Doppler of carotid and vertebral arteries showed a right vertebral artery flow pattern with mid-systolic deceleration (partial subclavian steal) – bunny rabbit sign. The angiotomography showed brachiocephalic trunk dissection with progression to the proximal third of the right subclavian and common carotid arteries. The right vertebral artery had its origin from the right subclavian artery (in its portion without dissection). Considering the patient’s clinical status, conservative clinical approach was adopted, with angiotomography and ultrasound of cervical vessels every six months.

Impotence due to External Iliac Steal Syndrome: Treatment with Percutaneous Transluminal Angioplasty and Stent Placement

We report a case of erectile dysfunction caused by external iliac artery occlusion, associated with pelvic steal syndrome; bilateral internal iliac arteries were patent. The patient stated that he had experienced erectile dysfunction at similar times along with claudication, but he did not mention it before angiography. He expressed that the erectile dysfunction did not last long and that he felt completely okay after the interventional procedure, in addition to his claudication. Successful treatment of the occlusion, by percutaneous transluminal angioplasty and stent implantation, helped resolve erectile dysfunction completely and treat the steal syndrome.

Síndrome do roubo da subclávia / Suclavian steal syndrome

A síndrome do roubo da subclávia refere-se a uma desordem vascular na qual ocorre inversão do fluxo de sangue da artéria vertebral ipsilateral, decorrente de uma estenose proximal à sua origem, geralmente uma oclusão da artéria subclávia ou, mais raramente, do tronco braquiocefálico. É uma doença relativamente rara, relatada em aproximadamente 6% dos pacientes assintomáticos com sopros cervicais. O Doppler pulsado (PW) é útil na análise da artéria vertebral, registrando informações capazes de identicar a presença da Síndrome do Roubo da Subclávia. Com base nas alterações hemodinâmicas da arteria vertebral avaliadas pelo estudo com Doppler Espectral, podem ser identificados três tipos de roubo da subclávia: oculto, parcial e completo. Com o advento da angioplastia transluminal percutânea e, em seguida, dos Stents, muitos advogam esta combinação de procedimentos como o tratamento de escolha dos casos sintomático desta síndrome.

combined approach to severe multi-organ atherosclerosis

Severe coronary artery disease often coexists with peripheral vascular atherosclerosis. The assessment of the supra-aortic circulation is, therefore, of clinical relevance. We herein describe a case of coronary artery disease treated with surgical revascularization using the internal mammary artery and thereafter the progressive atherosclerotic disease of the native coronary arteries as well as the left subclavian and left renal arteries. We also describe and discuss the clinical presentation, the diagnostic procedures, and the therapeutic approach with respect to the percutaneous transluminal angioplasty of the subclavian, renal, and right coronary arteries

Prevalência de estenose da artéria subclávia em pacientes candidatos a cirurgia de revascularização do miocárdio: registro multicêntrico / Prevalence of stenosis of the left subclavia artery in CABG candidates: a multicenter registry

Introdução: Aproximadamente 90 por cento dos pacientes submetidos a cirurgia de revascularização do miocárdio (CRM) recebem enxerto de artéria torácica interna esquerda. A ocorrência de estenose da artéria subclávia esquerda pode resultar em falência do enxerto por limitação de fluxo coronário. A prevalência de estenose da artéia subclávia esquerda em pacientes com aterosclerose coronária grave, considerados candidatos a CRM, não é conhecida. Objetivo: Determinar a prevalência e a eficácia da avaliação clínica para diagnóstico a estenose da artéria subclávia esquerda em candidatos a CRM. Método: Em um registro multicêntrico, realizou-se angiografia seletiva da artéria subclávia esquerda em pacientes com indicação de CRM na ocasião da cinecoronariografia. Estenoses maiores ou iguais a 50 por cento antes da origem da artéria torácica interna foram considerdas significativas. Resultados: Dos 205 pacientes estudados, 16 (7,8 por cento) apresentavam estenose significativa da artéria subclávia esquerda. A medida da pressão arterial não-invasiva diferencial entre...

Background: Approximately 90% of the patients submitted to coronary artery bypass graft surgery (CABG) receive a left internal thoracic artery (LITA) graft. Stenosis of the left subclavian artery can result in graft failure due to restricted coronary flow. The prevalence of stenosis of the left subclavian artery in patients with severe coronary atherosclerosis, deemed candidates to CABG, is not known. Objective: To assess the prevalence of stenosis of left subclavian artery in CABG candidates, as well as the diagnostic effectiveness of clinical evaluation. Methods: In a multicenter registry, selective angiography of the left subclavian artery was carried out in patients considered candidates to CABG during coronary cineangiography. Stenoses ≥ 50% proximal to the origin of the LITA were considered significant. Results: A total of 205 patients were included. Significant stenosis of the left subclavian artery was observed in 16 (7.8%) patients. Noninvasive differential arterial blood pressure measurement ≥ 10 mmHg between both arms showed low sensitivity (37.5%) and low positive predictive value (13.3%) for stenosis identification. No clinical predictors of significant stenosis were identified by univariate analysis. Conclusion: Stenosis of the left subclavian artery is not uncommon in CABG candidates. Noninvasive blood pressure gradient between both arms has low diagnostic accuracy. Therefore, in patients candidates to CABG, selective angiography of the left subclavian artery should be considered, because of the risk of reduced flow and coronary-subclavian steal syndrome in patients with non-diagnosed stenosis of the subclavian artery who receive a LITA graft.

Treatment of subclavian steal syndrome with percutaneous transluminal angioplasty and stenting. Case report

Subclavian steal syndrome refers to the association of neurological symptoms related to vertebrobasilar insufficiency and the phenomenon of subclavian steal. We report the case of a 63 year-old male patient that presented subclavian steal syndrome and severe proximal (80 percent) stenosis of the left subclavian artery. The patient was submitted to percutaneous transluminal angioplasty and stenting on the left SA. The procedure was well tolerated and immediately afterwards, there was complete remission of the symptoms and of the phenomenon of subclavian steal evaluated by angiography and transcranial doppler. We propose that percutaneous transluminal angioplasty with stenting placement is a good therapeutic option for subclavian steal syndrome