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.

Síndrome del robo de la subclavia / Syndrome of subclavian steal

Paciente femenina de 46 años de edad, con antecedentes de hipertensión arterial y fumadora habitual. Desde hace 2 años presenta episodios aislados y breves de vértigos, inestabilidad postural, sensación de desfallecimiento sin alteraciones de la conciencia, después de realizar ejercicios del brazo izquierdo. El examen neurológico muestra asimetría de pulsos carotídeos y radiales. El doppler extracraneal reveló alteraciones ateroscleróticas en ambos ejes carotídeos, con estenosis derecha del 50 %, disminución del flujo de la arteria vertebral izquierda y obstrucción proximal de la arteria subclavia izquierda proximalmente. El síndrome del robo de la subclavia es una entidad poco frecuente, su diagnóstico es clínico y se demuestra mediante doppler o angiografía. El tratamiento debe ser decidido individualmente en cada caso.

A 46 year-old female patient with a history of hypertension and regular smoker complained of isolated and brief episodes of dizziness, postural instability, faint feeling without altered consciousness, after exercise the left arm for 2 years. Her neurological examination showed asymmetry of carotid and radial pulses. Her extracranial doppler revealed carotid atherosclerotic changes in both axes, with 50 % right stenosis, decreased flow of the proximal left vertebral artery and obstruction of the proximal left subclavian artery. Subclavian Steal Syndrome is a rare condition. Its diagnosis is clinical and it is demonstrated by Doppler or angiography. Treatment should be determined individually in each case.

Sindrome del robo de la arteria subclavia: reporte de un caso / Steal syndrome subclavian artery: case report

It is the obstruction or estenosis of an artery’s proximal segment, which is close to the origin the vertebral artery. This causes blood flow inversion within the ipsilateral artery. An increase in the irrigation demands of the artery may cause TIA in the posterior circulation, which is denominated as subclavian steal syndrome. In these cases, contralateral circulation may contribute to prevention of several events due to hypoperfusion. In the case in which a subclavian estenosis accompanied by alteration in blood flow in the contralateral artery arises, symptoms corresponding to the irrigation area affected will be generated.

Se denomina de esta manera a la obstrucción o estenosis del segmento proximal de dicha arteria, cercano al origen de la arteria vertebral, lo que provoca inversión del flujo de la arteria vertebral ipsilateral. Un incremento en la demanda de la irrigación de la arteria vertebral puede provocar un AIT en la circulación posterior, o “robo de la subclavia”. De acontecer esto, existe el aporte de la circulación contra lateral que puede prevenir los diversos eventos debido a la hipoperfusión. De coexistir una estenosis de la subclavia con alteraciones de la circulación contralateral, se generaran los síntomas respectivos al área de irrigación afectada.

Síndrome de robo de la subclavia / Subclavian steal syndrome

Introducción. El síndrome de robo de la subclavia es una entidad rara que predomina en hombres, asociada a ateroesclerosis en mayores de 50 años y a patologías como la enfermedad de Takayasu en pacientes menores de 30 años. Su detección temprana para manejo quirúrgico es clave. Caso clínico: Evaluamos paciente masculino de 64 años de edad con historia de parestesias del miembro superior izquierdo y vértigo de cuatro meses de evolución, asociado a cambios en la presión arterial de ambos miembros superiores y pulsos disminuidos.Se solicitó estudio de angiotomografía de tórax, que evidenció trombosis por ateromatosis del tercio proximal de la arteria subclavia izquierda con circulación post estenosis por la arteria vertebral ipsilateral. El Doppler color reveló flujo retrógrado y turbulento con ausencia del pico diastólico final. Conclusión. Los hallazgos correspondieron a un síndrome de robo de la subclavia. El paciente fue referido para procedimiento quirúrgico.

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.

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.

Aporte de la angioresonancia con gadolinio en dos pacientes con síndrome de robo de la arteria subclavia / Angioresonancia contribution of gadolinium in two patients with steal syndrome subclavian artery

El Síndrome del robo de la subclavia es relativamente oscilando su incidencia entre el 0.22% y un 13.1%. La arteria izquierda es la más frecuentemente afectada (relación 3:1). Se presentan la clínica, fisiopatología, terapéutica y se discute la utilidad diagnóstica de la angiografía por resonancia magnética con contraste.

Subclavian steal syndrome as the presenting feature of hypervascular thyroid nodule.

Subclavian steal syndrome (SSS) is a clinical entity characterized by brachial and basilar insufficiency as a result of critical proximal subclavian artery stenosis or occlusion. We report a patient of giant hypervascular thyroid nodule presenting with features of SSS. The left hand ischemia and symptoms of vertebro-basilar artery in our patient were probably related to stealing of blood by the hypervascular thyroid nodule from the subclavian artery. The patient was relieved of the symptoms upon percutaneous subclavian stent placement.

Síndrome do roubo da subclávia: tratamento por angioplastia transluminar percutânea / Subclavian steal syndrome: treatment by percutaneous transluminal angioplasty

A síndrome do roubo da subclávia é doença cérebro-vascular incomum, que pode ser tratada por meio de técnicas endovasculares. São apresentados três casos dessa entidade, submetidos a angioplastia percutânea transluminar, fazendo-se breve revisão da literatura. Dois pacientes permanecem assintomáticos 23 e 30 meses, respectivamente, após o tratamento. Houve recidiva da lesão em um dos pacientes, 12 meses após o procediemnto. Pela baixa morbidade e pelos bons resultados técnicos e clínicos a angioplastia percutânea transluminar deve ser o método de escolha para o tratamento da síndrome do roubo da subclávia.

Síndrome do roubo da subclávia: relato de um caso / Subclavian steal syndrome: report of a case

Os autores relatam um caso de síndrome do roubo da subclávia, com comprovaçäo angiográfica, e fazem uma revisäo bibliográfica. Chamam a atençäo para a participaçäo desta síndrome no diagnóstico diferencial das isquemias cerebrais transitórias e das arteriopatias periféricas