Long-Term Outcome of Carotid-Subclavian Bypass in the Management of Coronary-Subclavian Steal Syndrome

OBJECTIVE

The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome.

METHODS

This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records.

RESULTS

Nine patients (all males, mean age of 69.1 years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1 months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9 months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft.

CONCLUSION

Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

The value of color Doppler sonography in diagnosis and hemodynamic analysis of innominate artery occlusion

The occlusion of the innominate artery caused a significant decrease in the distal end of the right subclavian artery and the right common carotid artery, internal carotid artery, and external carotid artery (ECA). Due to the different pressure and the abundant communicating arteries between the ECA and the bilateral vertebral artery (VA), different paths of blood steal in the anterior and posterior circulation occurred.

The use of 4-dimensional magnetic resonance angiography as a noninvasive procedure to diagnose subclavian steal syndrome in a dog

CASE DESCRIPTION

A 5-year-old 4.1-kg (9.0-lb) spayed female Toy Poodle was referred because of a 6-month history of sporadic signs of neck pain.

CLINICAL FINDINGS

Diagnostic imaging with MRI and CT revealed a dilated radicular artery connecting the right and left vertebral arteries and causing mild compression of the spinal cord. The left subclavian artery caudal to the origin of the left vertebral artery was absent. Subclavian steal syndrome (SSS) was suspected.

TREATMENT AND OUTCOME

The owner declined surgical treatment; thus, the dog was treated conservatively with glucocorticoids and analgesics. Eight months later, the dog's clinical signs were unchanged but palliated with the administration of glucocorticoids and analgesics, and 4-dimensional (4-D) magnetic resonance angiography (MRA) revealed that the left vertebral artery received blood supply from the right vertebral artery through the dilated radicular artery and that the left vertebral artery caudal to this site had retrograde flow and drained into the left subclavian artery, confirming the diagnosis of SSS. The owner again declined surgery, and conservative treatment continued. The dog's condition was unchanged at the last follow-up communication 11 months after 4-D MRA.

CLINICAL RELEVANCE

Subclavian steal syndrome is an extremely rare condition in dogs, and our findings suggested that 4-D MRA could be used to definitively diagnose SSS in dogs.

Don't Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.

Endovascular and Surgical Management of Subclavian Artery Occlusive Disease: Early and Long-Term Outcomes

BACKGROUND

The aim of the study was to report early and late outcomes of surgical and endovascular management of subclavian artery atherosclerotic disease (SAAD).

METHODS

Data about consecutive patients treated for subclavian artery atherosclerotic occlusive disease between 2001 and 2018 either by open surgical repair (OSR) or by endovascular repair (ER) were retrospectively collected and analyzed. Primary outcomes included 30-day death, as well as cardiac and neurologic events, reported separately for occlusion and stenosis. Secondary outcomes included primary patency in the long term, reported separately for occlusive and stenotic lesions. The Kaplan-Meier analysis with the logrank test was used to estimate long-term primary patency. Chi-squared and t-tests were used as appropriate to compare the outcomes of the 2 groups. A P value < 0.05 was considered statistically significant.

RESULTS

Sixty-eight patients were treated using ER (49 patients) and OSR (19). Technical success rate was 100% in both groups. During in-hospital stay, 1 brachial hematoma and 2 acute upper limb ischemia occurred in the ER group and in the OSR group, respectively. At 30 days, no deaths or neurological/cardiac events were recorded in both ER and OSR groups. Symptoms resolution and upper limb salvage were 100% in both groups. In the ER group, primary patency was 100% at 7 years in patients who had been treated for stenotic lesions and 62.5 ± 21.3% in patients who had been treated for occlusive lesions (P = 0.0035). In the OSR group, primary patency was 100% at 7 years in patients treated for stenotic lesions and 25 ± 21.6% in patients who had been treated for occlusive lesions (P < 0.0001). Overall, long-term primary patency in the OSR group was 76.9 ± 11.7% at 7 years, being lower than that reported after ER (93.4 ± 4.5%, P = 0.02).

CONCLUSIONS

Both ER and OSR proved to be safe, effective, and durable in the treatment of SAAD. In particular, the primary patency rates at long term for both ER and OSR showed better outcomes for stenotic lesions.

Endovascular versus surgical revascularization in proximal subclavian artery obstruction

BACKGROUND

The aim of this paper was to compare the outcomes of endovascular versus surgical treatment in patients with symptomatic proximal subclavian artery obstruction through a retrospective clinical study. Treatment of symptomatic subclavian artery obstruction can be performed with percutaneous transluminal angioplasty or open surgical reconstruction. Comparative studies are scarce.

METHODS

Technical success, patency and complication rates of 47 endovascular reconstructions in 46 patients were retrospectively compared with those of 19 open surgical reconstructions in 17 patients performed between 1996 and 2012. An additional series of 51 surgical reconstructions performed in the same institution between 1976 and 1993 served as a reference.

RESULTS

The technical success rate was 79% for endovascular and 100% for open surgical reconstructions (P<0.05). Primary patency was 72% and 89% at 1 year or 54% and 55% at 5 years for the endovascular and open surgical groups, respectively (log rank 0.210, P=0.65). Assisted primary patency was 77% and 100% at 1 year or 67% and 67% at 5 years, respectively (log rank 0.528, P=0.47). There was no mortality and major complications were infrequent, occurring equally in both groups (P=0.22).

CONCLUSIONS

Although with its less invasive character endovascular treatment has gained preference over surgical treatment of proximal subclavian obstruction in many cases, extrathoracic surgical reconstruction can be performed with a higher technical success rate, similar patency and a comparable number of complications.

Subclavian Steal Syndrome in Acute Myocardial Infarction Masquerading as Acute Embolism to Left Upper Extremity

Subclavian steal syndrome is an uncommon entity diagnosed with angiography after neurologic symptoms occur during activity with the upper extremity. Cardiac symptoms or silent ischemia have been described in patients who have undergone cardiac bypass using the ipsilateral internal mammary artery. Our patient presented with acute chest pain radiating to the left upper extremity and a diminished pulse. Angiography to rule out an acute embolus instead revealed subclavian artery occlusion. As atherosclerosis is the most common cause, the ipsilateral subclavian artery should be carefully evaluated, particularly in cardiac patients undergoing coronary angiography. Recognition of coexisting subclavian artery occlusion could prevent cardiac complications that may occur with use of the ipsilateral internal mammary artery during coronary artery bypass surgery.

Coronary-Subclavian Steal: Case Series and Review of Diagnostic and Therapeutic Strategies

Due to the increased use of internal mammary artery grafts for coronary revascularization, proximal subclavian stenosis resulting in coronary-subclavian steal has become an important clinical entity. Patients present with varying signs and symptoms of recurrent myocardial ischemia that not only can limit lifestyle but also be life-threatening. A careful history and physical examination with the identification of risk factors such as peripheral vascular disease and arm blood pressure differential >20 mm Hg can identify patents at high risk for developing this syndrome. Identifying these patients before coronary artery bypass grafting can prevent this important problem by altering the therapeutic approach to coronary revascularization. When patients present after coronary artery bypass grafting with coronary-subclavian steal, therapeutic options of percutaneous transluminal angioplasty and stent placement to the subclavian artery, carotid-subclavian bypass, and axillary-axillary bypass all have high success rates with excellent long-term patency rates. The choice for the type of revascularization needs to be individualized based on the lesion morphology and clinical comorbidities. Three patients who presented with signs and symptoms of myocardial ischemia due to coronary subclavian steal are presented. All 3 patients had incapacitating symptoms, and all 3 were treated successfully with different revascularization techniques due to other medical conditions or comorbidities.

Waveform patterns and peak reversed velocity in vertebral arteries predict severe subclavian artery stenosis and occlusion

This study investigated the value of analyzing spectral Doppler waveform patterns and measuring the peak reversed velocity (PRV) of the vertebral artery (VA) in predicting proximal severe subclavian artery (SA) stenosis and occlusion. Fifty-one patients with proximal SA stenosis were studied retrospectively. Based on the depth of the mid-systolic notch, the Doppler waveforms of the ipsilateral VA were divided into five subtypes (type I, n = 8; type II, n = 8; type III, n = 6; type IV, n = 13; and type V, n = 16). PRV was also measured. PRV receiver operating characteristic curves were constructed to obtain the best cutoff value for predicting severe SA stenosis or complete SA occlusion. The results indicated that both VA Doppler waveform and PRV were associated with the degree of SA stenosis (p < 0.05). PRV and the Doppler waveform in the VA had similar accuracy in predicting SA occlusion (84.3%, 43/51). PRV was more accurate than VA waveforms in predicting severe SA stenosis (98%, 50/51 vs. 94.1%, 48/51). However, no significant differences between the two methods in predicting severe SA stenosis were observed (p = 0.84). Thus, with severe obstruction of the SA, typical Doppler waveform patterns of the VA could be observed. PRV is a helpful criterion in predicting severe stenosis and occlusion of the SA.

Completely reversed flow in the vertebral artery does not always indicate subclavian steal phenomenon

We evaluated the causes, differential diagnosis and clinical significance of completely reversed flow (CRF) in the vertebral artery (VA). Twenty-three patients diagnosed with CRF in the VA by Doppler ultrasound were studied retrospectively. CRF was divided into intermittent CRF and continuous CRF. The peak reversed velocity (PRV) and ratio of time in intermittent CRF to one cardiac cycle (tICRF/CC) were calculated. Causes of CRF were determined on the basis of previous angiography results. The results indicated that subclavian steal phenomenon (SSP) caused all cases of continuous CRF (n = 8). Intermittent CRF was caused by SSP (n = 6) or proximal VA occlusion (n = 9). PRV and tICRF/CC were increased in SSP as compared with VA occlusion (p < 0.05). Using a cutoff of tICRF/CC = 0.30, we achieved excellent accuracy in predicting the cause of intermittent CRF (100%) and posterior circulatory infarction (91%). Thus, analysis of CRF patterns and measurements of VA parameters can be used in differential diagnosis of the causes of CRF and in prediction of posterior circulatory infarction.

Subclavian fusiform aneurysm causing partial subclavian steal syndrome. Case report

We present a 55-year-old man with repeated transient symptoms of vertebrobasilar arterial pathology. Physical examination detected no signs that would indicate the stenosis of the proximal subclavian artery segment. Ultrasound detected hemodynamic disorder of right vertebral artery, which correspond to a partial subclavian steal syndrome. Angiography shows fusiform aneurysm of ipsilateral subclavian artery in which central part is the base of hypoplastic vertebral artery. In the literature are rare reports of cases of partial subclavian steal syndrome caused by aneurysmal expansion of subclavian artery.

Peduncular hallucinosis in a patient with subclavian steal syndrome: usefulness of Doppler ultrasonography

The subclavian steal syndrome is characterized by retrograde flow within a vertebral artery ipsilateral to proximal subclavian artery high-grade stenosis or occlusion. It can cause vertebrobasilar insufficiency and hence diverse brainstem symptoms. Peduncular hallucinosis consists of visual images of brief duration that are related to thalamic or rostral brainstem lesions. We describe a patient with peduncular hallucinosis in the setting of subclavian steal syndrome. Inducing a hemodynamic challenge to the vertebrobasilar circulation elicited the patient́s visual symptoms. Thus, careful ultrasonographic evaluation with dynamic testing contributed to explain the physiopathology of the clinical symptoms.

An aberrant subclavian artery exhibiting the partial steal phenomenon in a patient with VACTERL association

We herein report the case of a 22-year-old Caucasian man with known vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, cardiac defects, renal and limb anomalies (VACTERL) association who presented with a headache and vertigo following the sudden and temporary loss of consciousness while attending a concert four days before admission to the hospital. On a physical examination, the following findings were found: a low body height, low-set ears, thoracic scoliosis and a mild holosystolic heart murmur. A neurosonological examination revealed a partial subclavian steal phenomenon. CT angiography of the neck vessels and aortic arch confirmed an anomalous right subclavian artery -known as the lusorian artery. Further studies are warranted in patients with VACTERL in order to identify possible links between the prevalence of an aberrant right subclavian artery (lusorian artery) and possible congenital subclavian steal syndrome or dysphagia lusoria. In addition, duplex ultrasound of the carotid and vertebral arteries may be performed as part of screening examinations in patients with congenital syndromes.

Bidirectional flow in the vertebral artery is not always indicative of the subclavian steal phenomenon

OBJECTIVE

To evaluate the causes of bidirectional flow in the vertebral artery detected by Doppler sonography and its differential diagnosis.

METHODS

Twenty-nine patients with bidirectional flow in the vertebral artery were retrospectively studied. The vertebral artery parameters, including peak antegrade velocity (PAV), peak reversed velocity (PRV), maximum peak velocity (MPV), peak systolic velocity, resistive index (RI), and diameter, were measured. The MPV was defined as the MPV of bidirectional flow regardless of the velocity of antegrade or retrograde flow. To better predict the cause of bidirectional flow, receiver operating characteristic curves were constructed for these parameters, and the best cutoff values were obtained. The cause of bidirectional flow was determined by angiography.

RESULTS

The causes of bidirectional flow were classified as the subclavian steal phenomenon (n = 21) and factors unrelated to the steal phenomenon (n = 8, including a hypoplastic vertebral artery [n = 4] and proximal vertebral artery stenosis and occlusion [n = 4]). Significant differences were observed between the steal phenomenon and non-steal phenomenon groups (P< .05) for MPV, PRV, PAV, target vertebral artery diameter, and contralateral RI. To determine the cause of bidirectional flow, areas under the receiver operating characteristic curves for the different parameters were obtained: 0.929 for MPV, 0.881 for PRV, 0.824 for PAV, 0.753 for target vertebral artery diameter, and 0.845 for contralateral RI. The cutoff value for MPV was 26.1 cm/s, and the accuracy was 93% (27 of 29).

CONCLUSIONS

Bidirectional flow in the vertebral artery is not always indicative of the subclavian steal phenomenon. Measurement of hemodynamic parameters in the vertebral artery, such as MPV, can facilitate determination of the cause of bidirectional flow.

Coronary subclavian steal from a left internal thoracic artery coronary bypass graft due to ipsilateral subclavian artery stenosis and an arteriovenous graft in a hemodialysis patient with left vertebral artery occlusion

Coronary subclavian steal syndrome is an unusual cause of myocardial ischemia, secondary to a reversed blood flow in patients with patent internal thoracic artery coronary bypass grafts. The causes of coronary subclavian steal are either ipsilateral subclavian artery stenosis or upper extremity arteriovenous hemodialysis fistula formation or both. This report involves a 68-year-old woman with left vertebral artery occlusion who developed severe coronary steal in the absence of vertebral subclavian steal due to left subclavian artery stenosis and an arteriovenous hemodialysis graft.

A review of subclavian steal syndrome with clinical correlation

Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.

[Subclavian artery stenting using gadolinium contrast medium in a case with iodine allergy]

The authors reported a subclavian artery stenting (SAS) using gadolinium contrast medium. The patient was a 65-year-old female who presented dizziness and right upper extremity pain with movement. Digital subtraction angiography revealed right subclavian artery occlusion with subclavian steal phenomenon. We tried to treat this lesion using SAS. However, iodinated contrast medium caused the allergy in this patient and the treatment was discontinued. Therefore, SAS was performed with gadolinium contrast medium. Using gadolinium contrast medium, it is possible to confirm large arteries like innominate artery and subclavian artery. The stenting procedure was performed without complication. The usage of gadolinium contrast medium has the limit and some strategies are important to reduce the usage of gadolinium contrast medium in SAS. First, PercuSurge GuardWire® was placed in the right internal carotid artery to confirm the anatomy, to decide working angle, and to treat the common carotid artery in case of dissection. Second, a "U" shaped guide wire was placed in the distal end from the brachial artery. Guide wire from femoral side was able to pass the lesion at midpoint of the "U" shaped one. SAS using gadolinium contrast medium may be an alternative treatment if a patient with subclavian artery stenosis or occlusion is allergic to iodinated contrast medium.

Evaluation of severe subclavian artery stenosis by color Doppler flow imaging

This study evaluates the diagnostic value of the hemodynamic parameters of color Doppler flow imaging (CDFI) for severe (70 to 99%) subclavian artery stenosis (SAS) using digital subtraction angiography (DSA) as the reference standard. Two-hundred fifty-two patients with suspected SAS were recruited into the study and examined from June 2005 to December 2009. The degree of stenosis was classified as moderate (50 to 69%) or severe (70 to 99%) stenosis. By using CDFI, the residual diameter (Dr), peak systolic velocity (PSV1) and end diastolic velocity (EDV) at the stenotic vessel segments, as well as the original diameter (Do) and PSV2 of the relative normal segments distal to the stenosis (the segment distal to the poststenotic dilation) were recorded. The diameter stenosis rate (1-Dr/Do) and PSV ratio (PSV1/PSV2) were calculated. Using DSA as the reference standard, the diagnostic values and optimal cutoff values for each parameter for the evaluation of severe (70%-99%) were determined using receiving operating characteristic curve analysis. Among the 252 patients, 109 patients were diagnosed as having severe (70 to 99%) SAS and 143 patients had moderate (50 to 69%) SAS. The optimal cutoff values for PSV1, EDV and the PSV1/PSV2 ratio for evaluating severe (70 to 99%) SAS were PSV1 ≥343 cm/s, EDV ≥60 cm/s and PSV1/PSV2 ≥4.0, respectively. The accuracy for diagnosing SAS with PSV1 (86.1%) was higher than that of EDV (85.7%), PSV1/PSV2 (84.9%) and 1-Dr/Do (80.2%). In addition, when PSV1 was used in combination with EDV and 1-Dr/Do, the accuracy for diagnosing SAS increased from 86.1% to 87.3%. When PSV1 was used in combination with EDV and PSV1/PSV2, the accuracy for diagnosing SAS reached 95.8%. In conclusion, the CDFI hemodynamic parameters of PSV1, EDV and PSV1/PSV2 show good consistency with DSA for diagnosing severe (70 to 99%) SAS, and a combination of these three parameters can ensure even greater accuracy for diagnosing SAS.

Chronic brainstem ischemia in subclavian steal syndrome

Subclavian steal syndrome is usually an incidental finding and rarely causes vertebrobasilar ischemia. We present a 58-year-old man who, over six months, experienced progressive slowing in both talking and walking. Cervical duplex sonography revealed severe stenosis of the right subclavian artery; fixed retrograde flow was noted in the right vertebral artery on transcranial Doppler. The hyperemia-ischemia cuff test resulted in considerable reduction in flow velocities in both posterior cerebral arteries. We attributed his slowness to chronic vertebrobasilar ischemia and surgical revascularization was performed. His symptoms subsided immediately after surgery. The improved perfusion in the posterior circulation was demonstrated on technetium-99 hexamethylpropyleneamine oxime single photon-emission CT. Early diagnosis and prompt treatment resulted in an improved quality of life.

Extracranial and intracranial sonographic findings in vertebral artery diseases

OBJECTIVE

The aim of this review is to illustrate the sonographic features that can be detected in vertebral artery (VA) diseases.

METHODS

We conducted a review of sonographic findings in VA diseases.

RESULTS

Various VA diseases are described, and sonographic techniques and features are discussed.

CONCLUSIONS

Posterior circulation vascular imaging can be performed by means of various neuroimaging techniques. Intra-arterial angiography remains the reference standard. The use of this technique has become even more widespread since it has become possible to perform endovascular procedures; it is, however, an invasive procedure that is associated with a not irrelevant level of risk. Computed tomographic angiography and magnetic resonance angiography with and without contrast agents have been proposed as less invasive alternatives, although these techniques can only be performed in the radiology unit and may not be readily available in daily clinical management. Sonography, which combines an extracranial and intracranial evaluation, is highly suited to the assessment of the vertebrobasilar system on account of its widespread availability and its unique capacity to study real-time hemodynamics. Furthermore, new sonographic applications and sonographic contrast agents have improved the sensitivity and specificity of this technique with regard to diagnostic accuracy for the posterior circulation.

Subclavian steal syndrome secondary to Takayasu arteritis in a young female Caucasian patient

Subclavian steal syndrome (SSS) is most frequently described in Caucasians aged over 50 years because of increased incidence of atherosclerosis in this population. Non-atherosclerotic etiologies of SSS are rare in Caucasians. We present a case of Subclavian Steal Syndrome secondary to Takayasu Arteritis (TA) in a 26 year-old female Caucasian patient. The present case underscores that despite the very low incidence of TA in Caucasians (0.8/1,000,000), this large-vessel vasculitis of unknown etiology should always be considered in the differential diagnosis of subclavian steal syndrome in Caucasian women aged less than 40 years.

Subclavian artery stent fracture

We report a case of a 52 year-old dentist who had stent implantation for a left subclavian artery stenosis. However, this was later complicated by a stent fracture within one week of stent placement. A chest radiograph showed two pieces of the fractured stent, which was confirmed by computed tomographic angiogram (CTA) of the affected artery. We then discuss the occurrence of stent fractures, which are not uncommon but serious complications of endovascular therapy.

Significant stenosis of proximal left subclavian artery presenting with absence of left radial pulse and recurrent angina after coronary artery bypass grafting

Stenosis of the subclavian artery, before the left internal mammary artery branch, is an important problem for patients who have undergone coronary artery bypass grafting, with an incidence rate of 0.5-1.1%. In this paper, a case of left subclavian artery stenosis, which developed after coronary artery bypass surgery and led to recurrent anginal attacks in the patient, is presented.

Evaluation of coronary subclavian steal syndrome using sestamibi imaging and duplex scanning with observed vertebral subclavian steal

Coronary subclavian steal is defined as retrograde blood flow from the myocardium through the internal mammary artery graft, secondary to a proximal subclavian artery stenosis. The incidence of this syndrome in patients undergoing internal mammary artery grafts for coronary artery bypass is estimated to be 0.44%. Angiography remains the definitive diagnostic test for confirming this condition. We describe a noninvasive method for evaluating coronary subclavian steal syndrome in a 57-year-old man, with a 50-55% subclavian stenosis confirmed by angiography. Noninvasive evaluation using duplex scanning demonstrated normal vertebral artery blood flow. Technetium 99m-sestamibi (99mTc) imaging confirmed a fixed anterolateral defect. When left-arm isometric exercise was employed, retrograde vertebral artery blood flow was observed by Doppler imaging. A repeat 99mTc-sestamibi study documented an increase in tracer distribution in the anterolateral defect confirming reperfusion of the myocardium through the left internal mammary artery graft. The use of duplex scanning and 99mTc-sestamibi may serve as an adjunct in evaluating coronary subclavian steal syndrome as well as documenting transient vertebral subclavian steal in this patient population.

Catheter-based management for the congenital coronary arteriovenous fistula indicated by the stress 99mTc-MIBI SPECT

A 10-year-old boy, who had suffered Kawasaki disease 7 years ago, presented chest pain, pale face, and cold sweating in the stress (99m)technetium-methoxyisobutylisonitrile ((99m)Tc-MIBI) single-photon emission computed tomography (SPECT), which showed reversible perfusion abnormality indicative of myocardial ischemia involving the right coronary artery. Angiography identified congenital coronary arteriovenous fistula (CAVF) from the right coronary artery to the main pulmonary artery, to which the patient's symptoms and signs of myocardial ischemia, by means of coronary steal phenomenon that entails reversible perfusion abnormality in the stress (99m)Tc-MIBI SPECT, could be ascribed. The penny shall finally be dropped without sudden cardiac event after coaxial transarterial coil occlusion on this boy with the congenital CAVF that is indicated significantly by the stress (99m)Tc-MIBI SPECT.

Percutaneous angioplasty and stenting of subclavian arteries before surgical coronary revascularization in a patient with an aberrant right subclavian artery

An aberrant right subclavian artery occurs in less than 2% of the population. An associated stenosis of the subclavian artery carries a risk of subclavian-coronary steal in patients who undergo coronary revascularization. We report on the case of a 54-year-old man admitted to our hospital for a coronary artery bypass graft (CABG). Angiographic examination revealed bilateral subclavian-artery stenosis with an aberrant right subclavian artery, anomalous origin of the right vertebral artery from the right common carotid artery, and left vertebral-artery occlusion. The patient underwent successful bilateral subclavian angioplasty and stenting.

[Endovascular recanalisation of subclavian artery stenotic-occlusive lesions]

Recently, percutaneous transluminal angioplasty (PTA) with stent placement has gained greater acceptance for the treatment of hemodynamically significant atherosclerotic lesions involving the brachiocephalic, subclavian and vertebral vessels. PTA is performed instead of extratoracic bypass surgery, which is associated with several risks and complications. Main indications for PTA and stent include short occlusions and elderly patients with increased surgical risk. We present 4 cases with occlusion of the left subclavian artery, including 1 case ofthombosed distal anastomosis of carotid-subclavian bypass.

Percutaneous transluminal angioplasty of the subclavian arteries

AIM

The aim of this study was to review the feasibility, safety and long-term results of subclavian artery (SA) angioplasty.

METHODS

Over 14 years, 237 patients (males: 135; mean age: 64+/-12 years) underwent percutaneous treatment for SA occlusive disease. Indications for treatment were upper limb ischemia (n=125), vertebrobasilar insufficiency (n=128), coronary steal (n=11) and anticipated coronary bypass surgery in asymptomatic patients (n=26). A total of 192 arteries were stenosed and 45 occluded. Mean percentage stenosis was 81.9+/-7.6% and mean lesion length was 23.8+/-8.8 mm. Percutaneous techniques included retrograde femoral (n=163), brachial artery (n=47) access or both (n=14) and in 4 cases the ''pull through technique''. An isolated balloon angioplasty was performed in 59 cases. We implanted 132 balloon expandable stents and 32 self-expandable stents.

RESULTS

Technical success was obtained in 223 lesions (94%). Only 31 occlusions were recanalized (69%). Four periprocedural events occurred (1.2%), 1 major (fatal) stroke, 1 transient ischemic attack and 2 arterial thromboses. At follow-up (mean follow-up: 65.8+/-33.5 months), we had 27 restenoses (12%). Thirteen occurred following angioplasty alone (18.8%) and 14 following angioplasty and stent implantation (8.4%). Primary (PI) and secondary (PII) patencies on an intention to treat basis at 10-year follow-up were 78.1% and 84.5%, respectively. In patients without initial stent placement, the rates were 67.5% and 75.5%, while in those with stents the rates rose to 89.7% and 96.9% (P<0.01). PI for all recanalized lesions were 84.6%, 79.1% without stent, 89.7% with stent (P<0.04) and PII 91.6%, 88.5%, 96.9%, respectively (P<0.02).

CONCLUSION

Percutaneous transluminal angioplasty is currently the treatment of choice for SA lesions. It is a safe and effective procedure associated with low risks and good long-term results. Stents seem to limit the restenosis rate and improve long-term results.

Concomitant multiple revascularizations in supra-aortic arteries: short-term results in 50 patients

BACKGROUND AND PURPOSE

The outcome for simultaneous revascularization of more than 1 supra-aortic arterial stenosis has not been evaluated because of concerns regarding the increased risk of additional procedures. We evaluated the feasibility and safety of concomitant multiple supra-aortic arterial revascularizations (CMSAR).

MATERIALS AND METHODS

We retrospectively evaluated 50 consecutive patients who underwent CMSARs with angioplasty and stent placement. The study included a separate lesion group (LG) (n = 28), ipsilateral LG (n = 17) including adjacent (n = 6) and remote (n = 11) tandem lesions, and triple LG (n = 5). We assessed the procedural success (defined as residual stenosis <30%) and periprocedural event rate (ER) (minor or major stroke, and death). We compared the ERs in the lesion (ipsilateral vs separate) and symptom (unstable vs stable) pattern groups with the Fisher exact test.

RESULTS

Procedural success was achieved in all patients (50/50). Periprocedural events within 30 days were noted in 5 (10%). ER within 2 days after the procedure was higher in the ipsilateral LG (4/17) than in the separate LG (0/28) (P = .016). Major events consisting of a major stroke and a death occurred in 2 patients in the unstable group (4%) and was more common in the unstable (2 of 7) than in the stable group (0/38) (P = .029). During the mean 11-month follow-up period, there was 1 symptomatic recurrence.

CONCLUSION

CMSARs are feasible with a high procedural success rate resulting in a favorable short-term outcome. However, they must be carefully performed in ipsilateral LG, especially in patients in the unstable group.

Anterolateral myocardial infarction induced by coronary-subclavian-vertebral steal syndrome successfully treated with stenting of the subclavian artery

A female patient with graft-dependent coronary circulation presented with vertebrobasilar insufficiency and NSTEMI (Non-ST-Elevation Myocardial Infarction) related to a 100 percent stenosis of the left subclavian artery. Our review of the medical literature indicates that this is the first reported case in which a patient presented with an anterolateral NSTEMI and dizziness with subsequent angiographic evidence of both coronary subclavian and vertebral subclavian steal syndromes successfully treated with angioplasty and stenting of the left subclavian artery without any intervention in the coronary arterial tree.

Surgical treatment of coronary subclavian steal syndrome

The internal mammary artery is the conduit of choice for cardiac revascularization. Atherosclerotic disease of the coronary arteries may simultaneously involve the subclavian artery. Proximal stenosis in the left subclavian artery may result in recurrent myocardial ischemia in patients with a patent left internal mammary artery (LIMA), due to coronary steal syndrome through the LIMA.

Coarctation of the Aorta Associated with Left Subclavian Artery Aneurysm: A Case Report

Aneurysm of the left subclavian artery (LSA) in association with coarctation of the aorta (CoAo) is a rare phenomenon, especially in the younger population. A 19-year-old male patient was admitted for lower extremity varices and diagnosed to have severe CoAo and a 45-mm LSA aneurysm after digital subtraction angiography following detection of nonpalpable lower extremity pulses on physical examination. Corrective surgery was performed from a left posterolateral thoracotomy through the 4th intercostal space, and a discrete ring-like coarctation tissue was observed in the aorta just below the level of the LSA orifice. Complete excision of the coarctation tissue was followed by aortoplasty with a Dacron patch. Additionally, the subclavian aneurysm was completely excised and a 10-mm Dacron tube graft interposition was performed. Prompt diagnosis and surgical treatment in particularly hypertensive patients precludes significant mortality and morbidity following a possible rupture.

Differentiation of thoracic outlet syndrome from treatment-resistant cervical brachial pain syndromes: development and utilization of a questionnaire, clinical examination and ultrasound evaluation

OBJECTIVE

The present study was undertaken to determine which factors differentiate patients with a good outcome after treatment for Thoracic Outlet Syndrome (TOS) from patients with a poor outcome.

METHODS

A total of 85 patients, who were examined during one year, had at least 6 months of follow up after treatment for TOS with either surgery or botulinum chemodenervation.

RESULTS

Socioeconomic factors of work disability or workers' compensation claims did not differentiate treatment-responsive TOS from treatment-resistant cases. There was no difference between the 2 groups regarding the presence of anomalous anatomy detected by ultrasonography or regarding the presence of subclavian artery flow acceleration or occlusion detected by duplex sonography. Several factors were noted more frequently in treatment-resistant patients: sensory complaints extending beyond lower trunk dermatomes (42% vs. 10%), weakness extending beyond lower trunk myotomes (19% vs. 2%), histories of previous non-TOS surgery of the neck or upper limbs (50% vs.17%), comorbidities of fibromyalgia or complex regional pain syndrome (81% vs. 12%), and depression (35% vs. 10%). Treatment-resistant patients complained about more widespread functional impairments on a validated Cervical Brachial Symptom Questionnaire (CBSQ) than treatment-responsive patients. Resistant cases responded less often to a scalene test block (38% vs. 100%), which is designed to simulate the effects of targeted treatment.

CONCLUSION

In summary, compared to patients with a good outcome after targeted treatment, patients with a poor outcome had more diffuse complaints and responded less often to a scalene test block.