A Novel Case of Anomalous Origin of Left Vertebral Artery Associated With Left Subclavian Steal Syndrome.

The subclavian steal syndrome (SSS) is defined by the reversal of flow in the ipsilateral vertebral artery in the setting of subclavian artery stenosis proximal to its origin. Here, we describe a rare case of left SSS with significant left subclavian artery stenosis associated with anomalous origin of the left vertebral artery (LVA) directly from the aortic arch in a patient presenting with signs of vertebrobasilar insufficiency and resolution of symptoms following angioplasty. Through this case, the authors try to emphasize the importance and the correct technique of using Doppler ultrasonography, and the importance of invasive angiography in understanding the mechanism of subclavian steal in patients with anomalous LVA origin.

Right-Sided Aortic Arch With Isolated Left Subclavian Artery, Subclavian Steal Syndrome, and Right Bronchial Compression: A Case Report.

A right-sided aortic arch with an isolated left subclavian artery represents a rare anatomical variant, posing diagnostic challenges and clinical complexities. Here, we present a case of a 14-year-old male presenting with respiratory symptoms, unveiling a right-sided aortic arch with an isolated left subclavian artery. Through detailed clinical evaluation, radiographic imaging, and diagnostic modalities including chest radiography, computed tomography angiography, ultrasound, and time-of-flight magnetic resonance angiography, the anatomical features and associated complications were delineated. The discussion encompasses embryological underpinnings, clinical manifestations, and therapeutic considerations, shedding light on the rarity and clinical implications of this anomaly.

Case Report: Right aortic arch with isolation of left brachiocephalic artery and ventricular septal defect.

Right aortic arch with isolation of left brachiocephalic artery is a rare congenital aortic arch anomaly. Herein, we reported a case of this rare anomaly with ventricular septal defect in a 9-month-old infant. We successfully reconstructed the islolated left brachiocephalic artery and repaired the ventricular septal defect in one stage.

Clinical study of 57 cases of endovascular treatment for total subclavian artery occlusion.

OBJECTIVE: To investigate the safety and efficacy of endovascular treatment for totally occlusive lesions of the subclavian artery (SCA). METHODS: A retrospective study was performed on 57 patients treated with angioplasty and stenting, including 42 males and 15 females, with an average age of 61.8 years (range: 49 to 81 years). Efficacy, safety, and complications were evaluated. RESULTS: Procedural success was achieved for 47/57 patients and symptoms were relieved. Rat-tail occlusion is the most common type, and all cases were successfully recanalized. Plain type occlusion is less common with a recanalization rate of 55.6%. Hilly and plain occlusions are the main types of stent implantation failure. Through univariate analysis and trend matching analysis, the type of SCA occlusion and surgical approach had statistical significance on the success rate of surgery. The mean follow-up time was 34.6 ± 16.2 months. The cumulative stent patency rates at 1, 3, and 5 years were 95.5%, 86.4%, and 77.3% in the calcified plaque group and 92.0%, 76.0%, and 68.0% in the non-calcified plaque group, respectively. The 3-year and 5-year patency rates in the calcified plaque group were higher than those in the non-calcified plaque group (p < .05). CONCLUSION: Different occlusion types and surgical approaches can affect the surgical success rate. The combined femoral and brachial approach can improve the rate of recanalization of SCA occlusions. The patency rates at 3 and 5 years in the calcified plaque group were higher than those in the non-calcified plaque group.

Relationship between subclavian artery stenosis lesions and posterior circulation infarction: A preliminary study.

OBJECTIVE: To investigate the correlation between subclavian steal syndrome and posterior circulation infarction using magnetic resonance imaging. METHODS: A total of 294 patients diagnosed with subclavian steal syndrome using carotid Doppler ultrasonography were retrospectively included. According to the magnetic resonance imaging results, they were divided into posterior circulation infarction group and non- posterior circulation infarction group. Clinical indicators and carotid Doppler ultrasound parameters of patients were collected, and they were screened to establish a multiple logistic regression model. Receiver operating characteristic curve analysis of the established multiple logistic regression model was performed, and the area under the curve was calculated to evaluate the predictive efficiency of the model. RESULTS: After statistical analysis of all parameters of the two groups of patients, a total of 10 parameters were included in multiple logistic regression to establish a model. The results showed a correlation between posterior circulation infarction and subclavian artery occlusion, grade III subclavian steal syndrome, gender, vulnerable plaques, National Institutes of Health Stroke Scale score, and age. After the receiver operating characteristic curve analysis of the model, the area under the curve for the multiple logistic regression model was 0.773. CONCLUSION: The multiparameter composite model based on clinical baseline data and carotid Doppler ultrasonography parameters can effectively predict posterior circulation infarction and offer novel insight for clinical diagnosis.

Subclavian steal syndrome: a case study of diagnosis, management, and successful surgical resolution.

Subclavian steal syndrome (SSS) is a rare vascular condition characterized by retrograde blood flow in the vertebral artery, often discovered incidentally in asymptomatic patients. We present a 65-year-old male with recurrent transient ischemic attacks (TIAs) attributed to 99% stenosis at the origin of the left subclavian artery, leading to SSS. Diagnostic modalities included duplex ultrasound, confirming inverted left vertebral artery flow, and multi-slice computed tomography angiography, confirming the diagnosis. Despite an unsuccessful attempt at balloon angioplasty, successful vascular surgery was performed, establishing a left carotid-vertebral artery bypass. The patient recovered well without complications. This case underscores the importance of considering SSS in TIA cases, utilizing non-invasive diagnostic tools, and highlighting the successful management of symptomatic SSS through surgical intervention.

Síndrome de robo de la subclavia tras tratamiento endovascular de aorta torácica / Subclavian steal syndrome after endovascular treatment of the thoracic aorta

Introducción: el síndrome de robo de la subclavia es una entidad poco habitual que se presenta en pacientes con estenosis u oclusión de la arteria subclavia, habitualmente la izquierda, y secundario a ateroesclerosis. Los síntomas derivados de esta entidad son: la isquemia del miembro superior y los síntomas neurológicos. Caso clínico: se presenta un caso de un varón que, tras cinco meses de tratamiento endovascular de úlcera de aorta torácica penetrante, presenta síntomas neurológicos. Se realizó diagnóstico del síndrome a través de eco Doppler y se confirmó con angio RM. Finalmente, y debido a la incapacidad que producían los síntomas, se decidió tratamiento quirúrgico mediante cirugía de bypass carótido subclavio izquierdo. Discusión: el síndrome del robo de la subclavia es una entidad que raramente se presenta asociada a síntomas. Debe tenerse una alta sospecha para diagnosticarlo y tratarlo si es necesario. Aunque la tendencia actual es el tratamiento endovascular, en ocasiones la cirugía de derivación tradicional es la única opción. Siempre que sea posible, debe estudiarse la dominancia de las arterias vertebrales antes de ocluir la arteria subclavia en los procedimientos. (AU)

Introduction: subclavian steal syndrome is a rare entity, occurring in patients with stenosis or occlusion of the subclavian artery, usually the left subclavian artery and secondary to atherosclerosis. The symptoms derived from this entity are: ischemia of the upper limb and neurological symptoms. Case report: we present a case of a man who, after five months of endovascular treatment of penetrating thoracic aortic ulcer, presented neurological symptoms. The syndrome was diagnosed by echo-Doppler and confirmed by MRI angiography. Finally, due to the incapacity caused by the symptoms, surgical treatment was decided by left carotid-subclavian bypass. Discussion: subclavian steal syndrome is an entity rarely presents with symptoms, it must be highly suspected in order to diagnose it and, if necessary, treat it. Although, the current trend is endovascular treatment, sometimes traditional bypass surgery is the only option. Whenever possible, the dominance of the vertebral arteries should be studied before occluding the subclavian artery in the procedures. (AU)

Impact of Vascular Access Flow Suppression Surgery on Cervical Artery Circulation: A Retrospective Observational Study.

Vascular access (VA) flow suppression surgery augments VA flow resistance and can increase other circulation flows hindered by high-flow VA. However, whether VA flow suppression surgery affects cervical circulation has rarely been reported. We aimed to determine the effect of VA flow suppression surgery on the cervical circulation in patients with high-flow VA. This single-center, retrospective, observational study included 85 hemodialysis patients who underwent VA flow suppression surgery at the Kanno Dialysis and Access Clinic between 2009 and 2018. Blood flow in the VA, bilateral vertebral arteries, and common carotid artery was measured before and after VA flow suppression surgery. The VA flow decreased from 1548 mL/min to 693 mL/min postoperatively. The flow of the vertebral artery on the VA side increased from 55 mL/min to 81 mL/min. The flow in the bilateral common carotid arteries also increased. Patients whose symptoms improved postoperatively showed better improvement in the vertebral artery on the VA side. VA flow suppression surgery in patients with high-flow VA increases the flow of the vertebral artery on the VA side and of the bilateral common carotid arteries. High-flow VA can hinder the vertebral and common carotid circulation.

Innominate artery occlusion: a case study.

Aim of the study: The aim of this case report is to evaluate carotid duplex and hemodynamic patterns in an asymptomatic male patient with innominate artery occlusion. Innominate artery occlusion is a rare clinical entity that can lead to a range of cerebrovascular symptoms, including arm claudication, subclavian steal syndrome, and stroke. The case report emphasizes key learning points in diagnosing innominate artery occlusion using imaging and physiological methods. Case description: A 64-year-old asymptomatic male patient with a history of carotid bruit, hypertension, coronary artery bypass grafting, aortic aneurysm, hyperlipidemia, mild aortic stenosis, long-term tobacco use, and a body mass index of 24 was referred for a carotid ultrasound. Conclusions: Innominate artery occlusion is a rare condition requiring a comprehensive assessment of collateralization before any intervention is attempted. Considering waveform features such as transient end-diastolic flow reversal and tardus parvus, along with brachial pressures and transcranial Doppler, can assist in evaluating the extent of disease.

Case Report: Kommerell's diverticulum and left aberrant subclavian artery stenosis hybrid treatment with branched aortic stent-graft.

Kommerell's diverticulum in association with left or right aberrant subclavian arteries is a rare finding and is challenging to treat. Contemporary surgical and endovascular techniques provide a broad arsenal of possible treatments. Imaging techniques and modeling technology allow a more personalized strategy for each patient. In this case, we present a symptomatic patient with a Kommerell's diverticulum and a left aberrant subclavian artery complicated by proximal stenosis and poststenotic aneurysm. A hybrid technique using a single-branched thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) in combination with a surgical left subclavian-carotid bypass and endovascular occlusion of the poststenotic aneurysm using a vascular plug device (Amplatzer Vascular Plug, Abbott, Chicago, United States) was performed. This approach was planned and facilitated by the use of a 3D model. Alternative treatment options and the strengths of this approach are briefly reviewed and discussed.

A case of carotid-axillary bypass for subclavian steal syndrome in an 83-year-old female undergoing hemodialysis.

INTRODUCTION: Patients undergoing hemodialysis exhibit a high incidence of subclavian steal syndrome. Many cases of endovascular treatment for subclavian artery stenosis were only reported recently; however, the long-term results of surgical treatment are also important. Herein, we report a case of subclavian steal syndrome treated with common carotid-axillary bypass surgery in a patient undergoing hemodialysis. PRESENTATION OF CASE: An 83-year-old woman experienced dizziness and pain in her left hand during hemodialysis. Computed tomography and angiography revealed severe stenosis and calcified lesions in the left subclavian artery. Ultrasonography revealed a retrograde blood flow waveform in the left vertebral artery. The patient was diagnosed with subclavian steal syndrome. We performed common carotid-axillary bypass for lesions that were difficult to revascularize via endovascular therapy. The post-operative course was uneventful, and the dizziness and numbness in the patient's left hand during dialysis disappeared. Post-operative ultrasonography revealed an antegrade blood flow waveform in the left vertebral artery. DISCUSSION: Subclavian steal syndrome is an indication for revascularization in symptomatic patients. Endovascular treatment should be considered the first choice; however, surgery should be considered for patients in whom endovascular treatment is difficult, such as those with severe calcification. We chose common carotid-axillary artery bypass because the subclavian approach is a more familiar technique. Until 1 year post-operatively, the patient had not experienced any symptom recurrence, and the shunt flow was well maintained. CONCLUSION: Common carotid-axillary bypass can be useful for revascularization of lesions for which endovascular therapy is considered difficult in patients with subclavian steal syndrome.

A rare association of subclavian steal syndrome with bilateral carotid artery stenosis: a case report.

Bilateral carotid artery stenosis in the context of subclavian steal syndrome is an extremely rare finding. We report the case of a 75-year-old woman who presented with a transient ischemic attack. Bilateral internal carotid stenosis associated with left subclavian steal syndrome was diagnosed. Left internal carotid endarterectomy was performed under locoregional anesthesia. Inflation of a blood pressure cuff reversed the neurologic symptoms that appeared after internal carotid clamping. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.

Outcomes of covered stents versus bare-metal stents for subclavian artery occlusive disease.

Objective: To compare the clinical efficacy of covered stents and bare-metal stents in the endovascular treatment of subclavian artery occlusive disease. Methods: Between January 2014 and December 2020, 161 patients (112 males) underwent stenting of left subclavian arteries; CSs were implanted in 55 patients (34.2%) and BMSs in 106 (65.8%). Thirty-day outcomes, mid-term patency, and follow-up results were analyzed with Kaplan-Meier curves. Relevant clinical, anatomical, and procedural factors were evaluated for their association with patency in the two groups using Cox proportional hazards regression. Results: Mean follow-up was 45 ± 18 months. The primary patency was 93.8% (95% CI, 81.9%-98.0%) in the covered stent group and 73.7% (95% CI, 63.2%-81.6%; P = 0.010) in the bare-metal stent group. The primary patency in the total occlusion subcategory was significant in favor of CS (93.3%, 95% CI, 61.26%-99.0%) compared with BMS (42.3%, 95% CI, 22.9%-60.5%; P = 0.005). Cox proportional hazards regression indicated that the use of BMSs [hazard ratio (HR), 4.90; 95% CI, 1.47-16.31; P = 0.010] and total occlusive lesions (HR, 7.03; 95% CI, 3.02-16.34; P < 0.001) were negative predictors of patency, and the vessel diameter (HR, 3.17; 95% CI, 1.04-9.71; P = 0.043)) was a positive predictor of patency. Conclusion: Compared with bare stents, covered stents have a higher midterm primary patency in the treatment of subclavian artery occlusive disease.

Subclavian steal syndrome in a right aortic arch with aberrant left subclavian artery atresia.

Congenital aortic arch anomalies are an uncommon diagnosis resulting from embryologic malformations during the fourth to eighth week of gestation. Asymptomatic variants frequently are overlooked in the perinatal period and diagnosed incidentally during adulthood. Symptomatic variants can present with steal syndrome or dysphagia lusoria. The right aortic arch is a rare anomaly that is usually associated with other congenital anomalies but can occur in isolation. The most common types of right aortic arches are mirror image branching or an aberrant left subclavian artery. Aortic arch anomalies are important to recognize as they may have important implications in management. We present a 74-year-old female with a right aortic arch and aberrant left subclavian artery that was discovered after a fall. An extensive evaluation and work-up revealed symptoms consistent with subclavian steal syndrome that resolved following a carotid-axillary bypass. Subclavian steal secondary to a right aortic arch is extremely rare. This report reviews the current literature of a right aortic arch with an aberrant left subclavian artery presenting as a subclavian steal syndrome.

Feasibility of Intravascular Lithotripsy for the Treatment of Calcified Supra-Aortic Vessels: A Case Report and Literature Review.

PURPOSE: To report a case of coronary-subclavian steal syndrome (CSSS) due to a history of a left internal mammary artery (LIMA) to left anterior descending (LAD) artery coronary bypass (CABG) and a heavily calcified ostial left subclavian artery (LSA) occlusion, that was treated with intravascular lithotripsy (IVL) technique and to summarize the current trends of IVL treatment for supra-aortic vessels. CASE REPORT: A 64-year-old woman with progressive intermittent angina pectoris and a history of LIMA to LAD bypass underwent coronary angiography which demonstrated complete ostial occlusion of the LSA. Via brachial access, the patient underwent Shockwave IVL balloon treatment of the LSA and stent-graft implantation. At 9 months follow-up, the patient showed symptoms resolution, and duplex ultrasound (DUS) demonstrated a patent LSA. CONCLUSIONS: The Shockwave IVL system was demonstrated to be a feasible treatment and justified for selective cases of highly calcified lesions in supra-aortic vessels. The present case report and the literature review, in a total of 47 patients resulted in a high technical procedural success rate, with a low rate of complications. Future studies with larger cohorts are warranted to confirm these findings and standardize this technology in this particular vascular field. CLINICAL IMPACT: The present study exemplifies a case of recanalization of the left subclavian artery in a patient with coronary-subclavian steal syndrome with a heavily calcified ostial lesion treated with intravascular lithotripsy (IVL). In this paper, for the first time, a review of the contemporary literature on the use of IVL in supra-aortic vessels is reported, elucidating the feasibility of this technique in this vascular territory. Despite the heterogeneous features of the reported cases and the lack of a standardized protocol for the use of IVL in the management of highly calcified lesions of supra-aortic vessels, it was demonstrated to be a feasible technique, with a high technical success rate, being an advantageous tool for heavily calcified supra-aortic lesions.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Subclavian Steal Syndrome as the Initial Presentation of Takayasu's Vasculitis in a Young Caucasian Female.

Takayasu arteritis (TAK) is a rare but well-known inflammatory disease affecting large vessels that leads to thickening, narrowing, occlusion, or dilation of the affected arteries. The overall effect of the disease is arterial insufficiency of the brain and/or the distal part of the affected vessel. Subclavian steal syndrome has been observed as a form of presentation where there is occlusion of the proximal subclavian artery that results in a reversal of flow in the ipsilateral vertebral artery, consequently diverting or 'stealing' blood from the contralateral vertebral artery. Our patient is a 34-year-old Caucasian female presenting with subclavian steal syndrome as the initial presentation of TAK. She presented to the emergency department following a syncopal episode and six months prior history of intermittent lightheadedness, vertigo, left upper extremity pain, numbness, and tingling which was said to be aggravated with activity and alleviated with rest. Examination findings revealed non-palpable left brachial and radial pulses of the upper limb with an inaudible blood pressure reading on the ipsilateral side and blood pressure of 113/70 mmHg on the contralateral arm. Investigation revealed elevated acute phase reactant, normocytic anemia, and inflammation of the aorta on imaging. She was evaluated by the vascular surgery team who recommended medical management. The patient was managed with steroids and methotrexate, and her symptoms improved significantly with the normalization of laboratory findings. She is currently being followed up by the vascular surgery and rheumatology teams. We emphasize the importance of understanding the varied clinical spectrum of TAK and the need to have a high index of suspicion for TAK in a young female with recurrent syncope and unilateral upper extremity intermittent numbness and paresthesia.

Acute heart failure due to coronary subclavian steal syndrome after coronary artery bypass grafting.

Key clinical message: An axillo-axillary bypass grafting is useful for coronary subclavian steal syndrome when occlusion of the proximal left subclavian artery. Abstract: An 81-year-old female who had undergone coronary artery bypass grafting 15 years previously was admitted and diagnosed with coronary subclavian steal syndrome. Preoperative angiography showed backflow from the left anterior descending coronary artery to the left internal thoracic artery and occlusion of the proximal left subclavian artery. Axillo-axillary bypass grafting was successfully performed.

Endovascular treatment of Takayasu arteritis in a middle-aged woman with syncope and limb claudication: a case report.

Takayasu arteritis (TA) is a disease that causes inflammation and stenosis of medium to large blood vessels. We report a case of a 50-year-old female patient with newly developed hypertension, syncope, and claudication of the extremities. Total occlusion of the left subclavian artery at the origin was found and significant stenosis of the right common iliac artery was revealed by hemodynamic analysis. She was successfully treated with percutaneous angioplasty for multiple peripheral arterial diseases and was finally diagnosed with TA. In consultation with a rheumatologist, medical treatment for TA was initiated, the patient's hypertension disappeared, and her claudication symptoms improved.