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%) 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.     

Effect of subclavian syndrome on the basilar artery

Fifty-five patients with a permanent or intermittent subclavian steal syndrome demonstrated by continuous wave Doppler were included in a prospective study: 25 patients without vertebro-basilar symptoms, 8 symptomatic patients with defined vertebro-basilar symptoms and 22 with hemodynamic vertebro-basilar occurences. The basilar artery velocity was recorded by Transcranial Doppler Sonography in baseline conditions, and after a hyperaemia test to the upper limb. A spontaneous, incomplete basilar steal was diagnosed in seven patients, and a complete basilar steal in one patient, (14.5% of the cases). After hyperaemia test, 18 other incomplete basilar steal were observed. The occurence of a basilar steal was higher in the vertebro-basilar group (57% of the cases) especially in 7 of the 8 cases with defined vertebro-basilar symptoms; it was lower in the patients without vertebro-basilar occurences (36% of the cases). This basilar steal was also seen in five of the six symptomatic patients with opposite vertebral artery stenosis above a 50% diameter. Transcranial Doppler Sonography could help to define a subgroup of subclavian steal syndrome with a high risk of strokes.     

Subclavian Steal and a Persistent Trigeminal Artery

A persistent trigeminal artery (PTA) has been found in a number of cerebrovascular diseases. A 73-year-old asymptomatic woman was noted to have a left PTA and left subclavian steal by catheter angiography. Carotid duplex revealed a peak systolic flow velocity of 294 cm/s in the internal carotid artery (ICA) and an ICA to common carotid artery ratio > 4, suggestive of a high-grade stenosis. Only a low-grade stenosis was identified by catheter angiography. The elevated flow velocities in the left ICA were attributed to increased collateral blood flow across the stenosis to the left PTA, which compensated for the subclavian steal. Transcranial Doppler found an alternating flow pattern in the basilar artery (mean flow velocity [MFV] = 18 cm/s) and left vertebral artery (MFV = 43 cm/s). During brachial hyperemia, the MFV increased by 178% in the basilar artery and 102% in the left vertebral artery. The data suggest that a PTA may compensate for subclavian steal and may have a protective hemodynamic role in this setting.     

血管内介入治疗锁骨下动脉盗血综合征临床研究

目的探讨应用血管内介入治疗锁骨下动脉盗血综合征的有效性和安全性。方法回顾性分析53例经血管内介入的锁骨下动脉盗血综合征患者的临床资料,从手术成功率、手术并发症及术后随访情况观察血管内介入治疗的有效性和安全性。结果 45/53例(84.90%)锁骨下动脉狭窄患者和8/53例(15.09%)完全锁骨下动脉闭塞患者均成功进行了血管内介入治疗,术后症状明显缓解。53例患者中发生手术并发症5次(9.43%),但未出现神经功能缺损和危及生命的手术并发症。锁骨下动脉闭塞的手术并发症发生率(37.50%)较锁骨下动脉狭窄(4.44%)显著升高(P0.05)。随访50/53例患者,随访率94.34%,平均随访时间(18.6±1.2)个月。1例患者术后12个月再狭窄率超过90%,行二次球囊成型;其余患者预后良好。结论应用血管内介入治疗锁骨下动脉盗血综合征具有微创、安全、高效优点,可作为首选治疗方法。     

Prenatal multicystic encephalomalacia due to anomaly of the aortic arch

Multicystic encephalomalacia (ME) usually results from severe hypoxic-ischemic brain damage occurring during the late third trimester of gestation and birth. We report on a case of congenital ME due to a congenital anomaly of the aortic origin of brachiocephalic vessels resulting in subclavian steal syndrome. A 5-day-old term neonate presented with microcephaly and overlapping cranial sutures. Both arms were developed normally. Magnetic resonance imaging of the brain showed extensive bilateral supratentorial ME. Color duplex sonography of the aortic arch and the intracranial and extracranial vessels revealed a stenosis at the origin of the left common carotid artery and atresia of the origin of the left subclavian artery resulting in left-sided subclavian steal syndrome and retrograde perfusion of the basilar artery. Total cerebral blood flow volume was reduced to 22 mL/min. Severely reduced cerebral blood flow volume resulted from left carotid artery stenosis and atresia of the origin of the left subclavian artery with consecutive subclavian steal. Infratentorial brain structures and the left arm remained intact, but supratentorial brain structures were severely affected with ME.     

Subclavian Steal Syndrome Like Appearance Resulting from a Vertebral Artery Origin Stenosis: A Case Report

Partial steal has been regarded as a classic ultrasound appearance of subclavian steal syndrome. We report a case with the vertebral artery origin stenosis and intact subclavian artery, which showed the similar partial steal ultrasound features. The following computerized tomography angiography confirmed the stenosis. Therefore, when an alternating flow in the vertebral artery is detected, the investigation of its origin must be performed besides the ipsilateral subclavian artery.     

重度锁骨下动脉盗血综合征的侧支代偿及临床特点

目的探讨重度锁骨下动脉盗血综合征(SSS)的侧支代偿及临床特点。方法回顾性分析12例经全脑数字减影血管造影(DSA)证实为重度SSS患者的临床资料。结果 12例SSS患者主要临床表现为发作性头晕、视物旋转、跌倒等,活动同侧上肢后症状加重;DSA示左侧锁骨下动脉重度狭窄或闭塞10例,双侧锁骨下动脉重度狭窄2例;侧支代偿途径椎动脉-椎动脉-锁骨下动脉10例,颈内动脉-后交通动脉-大脑后动脉/基底动脉8例,颈外动脉-枕动脉下支-椎动脉肌支动脉-椎动脉-锁骨下动脉9例。8例患者行锁骨下动脉支架成形术后临床症状完全消失;2例患者因锁骨下动脉闭塞及对侧椎动脉中度狭窄而接受对侧椎动脉支架成形术,术后症状减轻;随访3个月～2.5年,症状无复发。结论重度SSS临床表现主要为发作性头晕,侧支代偿途径主要为椎动脉-椎动脉-锁骨下动脉,支架成形术可纠正血流动脉动力学紊乱,缓解临床症状。     

Pitfall of Electron Beam Computed Tomography Angiography in Diagnosis of Subclavian Steal Syndrome

A patient presented with vertebrobasilar insufficiency during exertion. Vertebral duplex and transcranial Doppler ultrasonography showed reversal of flow in both intracranial and extracranial vertebral and basilar arteries, suggesting bilateral subclavian and vertebrobasilar steal. Electron beam computed tomography angiography (CTA) showed no evidence of subclavian artery stenosis including normal vertebral artery origin on both sides. However, digital subtraction angiography revealed complete occlusion of both subclavian arteries with retrograde flow from both vertebral and basilar arteries to reconstitute both subclavian arteries. This false-negative finding on CTA in detection of subclavian steal syndrome (SSS) is due to inappropriate contrast administration technique and postprocessing method, inability to differentiate flow direction, and lack of hemodynamic time sequences. This study demonstrates a pitfall of CTA in diagnosis of SSS compared to more reliable hemodynamic information obtained by duplex and transcranial Doppler ultrasonography, and digital subtraction angiography.     

Subclavian steal phenomenon Clinical and hemodynamic aspects

Fifty-eight patients with subclavian artery stenosis were classified as having definite or probable vertebrobasilar symptoms, carotid symptoms or no symptoms. The vertebral artery flow pattern was graded as no subclavian steal (Grade 0), systolic deceleration (Grade 1), alternating flow (Grade 2), or reversed flow (Grade 3). We found a statistically significant association between the occurrence of vertebrobasilar symptoms and the subclavian steal phenomenon Grades 2-3. No significant association could be established between time course, type or severity of symptoms and grade of steal phenomenon. The flow disturbance is probably one causal factor for the occurrence of symptoms. Reversed vertebral artery flow is commonly asymptomatic, however, and other non-identified cofactors must be operative in symptomatic patients.     

Endovascular Cerebral Protection and Revascularization of Innominate Artery Stenosis Through Single‐Site Access,with Device Entrapment and Rescue: Technical Case Report

We describe a novel technique for cerebral embolic device placement with inadvertent entrapment and subsequent rescue in the endovascular treatment of innominate artery stenosis. A 62‐year‐old female presented with symptomatic right‐sided subclavian steal syndrome. Single‐site access for revascularization of critical innominate artery stenosis with simultaneous cerebral embolic protection performed for this diagnosis has not been previously reported. Initial nontarget self‐expanding stent deployment within the right subclavian artery resulted in entrapment of the embolic protection device. The device was retrieved through snare fixation and resheathing within a 6‐French guide catheter navigated through common femoral artery access. Innominate artery balloon‐mounted stent angioplasty was performed preceded by the embolic device retrieval, with complete resolution of symptoms. Endovascular distal protection device placement for prevention of cerebral atherothromboembolism during innominate artery stent angioplasty is not without risk and utilization needs to be carefully considered.     

经颅多普勒超声诊断锁骨下动脉盗血综合征的分析

目的:分析锁骨下动脉盗血患者的椎动脉血流速度及频谱的改变,探讨经颅多普勒超声在诊断锁骨下动脉盗血综合征的临床意义及可靠性。方法:用经颅多普勒超声仪检测双侧椎动脉血流速度及观察频谱的变化,并经彩色多普勒超声证实锁骨下动脉/或无名动脉是否存在血管的闭塞或狭窄。结果:患侧椎动脉血流速度减慢,对侧椎动脉血流速度增快及基底动脉血流速度增快或正常范围内,部分盗血者频普收缩峰反向或完全盗血者患侧椎动脉呈典型的全心动周期反向血流频谱;基底动脉血流速度正常或与健侧椎动脉血流速度代偿性增快。束臂试验阳性。结论:经颅多普勒超声可诊断锁骨下动脉盗血综合征,可以提高诊断锁骨下动脉盗血综合征的可靠性,为临床及早的诊断和治疗提供了的依据。     

锁骨下动脉盗血综合征经颅多普勒超声检查临床价值

目的研究锁骨下动脉盗血综合征(SSS)的经颅多普勒超声(TCD)表现,并结合数字减影血管造影(DSA)检查探讨TCD对于SSS的诊断和治疗的临床意义和应用价值。方法分析69例经TCD诊断为SSS患者的血流动力学变化,根据患侧椎动脉(VA)频谱特点将盗血分为Ⅰ、Ⅱ、Ⅲ期盗血。初步判断盗血途径,分为健侧VA和/或基底动脉(BA)参与盗血。其中部分患者(39例)行DSA检查,根据DSA检查结果将锁骨下动脉(SubA)狭窄程度分为轻度狭窄(狭窄程度≤50%)、中度狭窄(狭窄程度51～75%)、重度狭窄(狭窄程度76～95%)和闭塞四组。并将各组检查结果与TCD检查结果进行对照分析研究。结果在TCD检查示Ⅰ期盗血的6例患者中,DSA示SubA轻度狭窄患者3例,中度狭窄3例;TCD检查示Ⅱ期盗血的16例患者中,DSA示SubA中度狭窄患者8例,重度狭窄7例,闭塞1例;TCD检查示Ⅲ期盗血的17例患者中,DSA示SubA中度狭窄2例,重度狭窄8例,闭塞7例。TCD检查所发现的盗血程度与DSA检查发现的SubA狭窄程度呈正相关(r=0.78)。结论 TCD是诊断SSS敏感而可靠的方法,为临床早期诊断和治疗提供了可靠的依据。     

Subclavian steal phenomenon complicating an upper extremity arteriovenous fistula for hemodialysis]

We report a case of 47-year-old man with subclavian steal phenomenon (SSP). He affected chronic renal failure and received an upper extremity arteriovenous fistula creation for hemodialysis. Angiography showed SSP from right vertebral artery to left subclavian artery (SA), and mild stenosis of left SA. We consider that the course of SSP was synergetic effect of mild SA stenosis and hemodynamic effect due to arteriovenous access creation.     

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.     

A patient with vertebrobasilar transient ischaemic attacks and provokable basilar steal

In a 65-year-old woman with vertebrobasilar transient ischaemic attacks (TIAs) and subclavian steal, a steal phenomenon in the basilar artery could be demonstrated by transcranial Doppler sonography after provocation with postischaemic hyperaemia of the arm on the affected side. It was not possible to provoke symptoms or signs at the time. The significance of finding a steal phenomenon in the basilar artery even in a patient with a history of vertebrobasilar TIAs is discussed.     

Anomalous Variations of the Origin and Course of Vertebral Arteries in Patients with Retroesophageal Right Subclavian Artery

We present two rare cases of anomalous vertebral artery (VA) with retroesophageal right subclavian artery. One patient had a right VA arising from the right common carotid artery (CCA), and a left VA originating from the third branch off the aorta. Both VAs ascended anteriorly to the transverse foramen of C5 to C6 vertebra and entered the transverse foramen of C4. The other patient had a right VA arising from the right CCA and entering the transverse foramen of C5. The presence of anomalous variations of the origin and course of vertebral artery might have serious implications in angiographic and surgical procedures, and it is of great importance to be aware of such a possibility.     

经颅多普勒超声及彩色多普勒超声联合检测在诊断锁骨下动脉盗血综合征中的应用

目的 通过分析锁骨下动脉盗血综合征(SSS)患者经颅多普勒超声(TCD)及彩色多普勒超声(CDU)的检测结果,探讨二者对SSS的诊断价值.方法 SSS患者94例,均经TCD和CDU确诊,且有11例经DSA检查证实.采用德国EME公司的TC-8080经颅多普勒超声及美国GE公司的LOGIQ BOOK彩色多普勒超声.根据同侧椎动脉(Ip-VA)检测的血流方向,将盗血程度分为:I度盗血(Ip-VA收缩期有切迹);II度盗血(Ip-VA舒张期正向,收缩期反向);III度盗血(Ip-VA完全反向).结果 94例SSS患者中多发性动脉硬化88例,大动脉炎6例,其中锁骨下动脉狭窄96条,平均管径为0.9～3.9mm,血流速度范围150～500cm/s,闭塞4条.I度盗血占45%;II度盗血占35%;HI度盗血占20%.基底动脉参与盗血的患者6例,大脑后动脉参与盗血2例.11例行DSA检查患者中,有4例闭塞或几乎闭塞.4例狭窄在75%～95%,3例狭窄在50%～74%.结论 将TCD与CDU相结合不仅可以观察盗血的程度和途径,而且可以明确狭窄的病因及程度,且二者无创、经济、简便,可作为锁骨下动脉盗血综合征的首选检查手段,并可用于评价治疗效果及长期随诊.

Abstract：

Objective By oserving the phenomenon of subclavain steal syndrome(SSS) with Transcranial Doppler ultrasonography (TCD) and Color Doppler ultrasonography ( CDU) ,to analyze the diagnostic value of them in SSS. Methods 94 patients were diagnosed as SSS by TCD and CDU, 11 of them were verified with digital substract angiography ( DSA). Double MCA, ACA,PCA, VA and BA were examined with 2MHz probe of TCD. The lumen and intima-media of carotid, vertebral , subclacian and innominate arteries were displayed with two-dimensional ultrasonography and their blood flow velocity and direction were detected by color and spectral Doppler ultrasonography with LOGIQ BOOK computed sonography. According to the direction of ipsilateral VA (ip-VA ) , the subclavian steal syndrome ( SSS) were defined as stage I ( deceleration in systole) , stage II ( alteration flow with reversed flow in systole and normal flow in diastole) and stage III ( reversed flow completely). The steal pathway was defined as basilar artery steal pathway (with steal waveform in basilar artery ( BA) ) or non-basilar artery steal pathway ( normal direction in BA). Results 88 patients of SSS were caused by atherosclerosis, 6 patients by aortoarteritis. 96 had subclavian arterial stenosis with lumen diameter 0. 9 ～3. 9mm and the velocity 150 ～500cm/s,occlusion of subclavian occurred in 4 patients 45% had steal stage I ,35% had steal stage II ,20% had steal stage III. 6 patients had basilar artery steal pathway and 2 patients had posterior cerebral arteryl steal pathway. Occlusion or nearly occlusion of subclavian were 4 patients with DSA. The severity of subclavain of 4 patients was 75% ～95% and other 3 was 50% ～ 74 %. Conclusion TCD combine with CDU is a sensitive and reliable method for evaluating the steal phenomena in patients with subclavian artery stenosis, they can not only observe the degree and path ways of steal phenomena , but also can indetify the etiopathogensis and severity of stenosis, and they are economic, convenient, no-injured, so they can be the first and foremost dignosis method for SSS, they also can be used to evaluate therapeutic effect and long-term follow-up.     

Hemodynamics of the vertebral artery in subclavian steal syndrome and subclavian steal phenomenon]

To evaluate hemodynamics of the vertebral artery (VA) in subclavian steal syndrome (SSS) and subclavian steal phenomenon (SSP), blood flow velocities of the bilateral VAs were measured by duplex ultrasonography in four patients with SSS and eight patients with SSP. The reversal of flow in the VA was noted in both systolic and diastolic phases in all of the SSS group, and was recorded only in a systolic phase in all but one of the SSP group. The antegrade mean flow velocities in the VA on the unaffected side in the SSS group were significantly higher than those in the SSP group. This indicates that collateral blood flow through the VA in the SSS group is still insufficient to compensate the blood requirement of the upper extremity on the affected side. In conclusion, hemodynamics of the VA in the SSS group could be distinguished from those in the SSP group by duplex ultrasonography.     

锁骨下动脉盗血综合征5例临床分析和文献复习

目的：通过全脑血管造影观察锁骨下动脉盗血综合征（SSS）患者的颅外侧支循环代偿模式及血管内支架治疗的疗效。方法：通过全脑血管造影对5例SSS患者的颅外侧支循环代偿模式进行观察,行血管内支架治疗并随访2～13个月,观察术后疗效并复习相关文献。结果：5例患者共置入6枚支架。颅外侧支循环代偿途径中,出现枕动脉与椎动脉肌支吻合血管开放4例,无吻合1例;吻合后向颅内供血1例,双向供血1例,向颅外供血2例,其中1例同时伴后交通动脉开放前循环向后循环供血;1例锁骨下次全闭塞患者因术中多次行球囊扩张而术后并发非感染性动脉内膜炎。结论：血管内支架治疗锁骨下动脉盗血综合征安全有效,在颅外侧支循环代偿途径中,枕动脉与椎动脉肌支间吻合发挥重要作用,且有多种不同代偿模式,重度狭窄行血管成形术时应警惕非感染性动脉内膜炎的发生。     

锁骨下动脉闭塞血管内再通治疗的可行性分析

目的 探讨慢性锁骨下动脉闭塞血管内再通治疗的可行性、安全性与有效性。 方法 回顾性分析2014年1月-2018年6月首都医科大学附属北京天坛医院神经介入中心收治的慢性 锁骨下动脉完全闭塞且存在病变侧上肢远端肢体乏力等缺血症状或明确诊断为锁骨下动脉盗血综 合征（subclavian steal syndrome，SSS）患者的临床资料。分析血管内治疗慢性锁骨下动脉闭塞的血管再 通成功率、围手术期并发症（30 d内缺血性卒中、心肌梗死和血管性死亡）及术后血管再狭窄等指标。 根据血管内治疗后闭塞的锁骨下动脉开通结果分为成功再通组及再通失败组，比较两组一般资料 和临床特点。根据成功再通组患者所用支架类型分为自膨式支架组和球扩式支架组，比较两组术后 血管残余狭窄率的差异。对成功再通的患者进行随访，根据是否出现术后血管再狭窄分为术后再狭窄 组和无术后再狭窄组，比较两组的一般资料和临床特点。 结果 共纳入106例符合入组标准的患者，男性87例（82.1%），女性19例（17.9%），中位年龄61.0 （56.8～67.0）岁。有91例（85.9%）血管成功再通，15例（14.2%）血管再通失败，成功再通组及再 通失败组的人口学信息、既往史、发病到治疗时间等临床特征差异无统计学意义。所有患者均无 围手术期并发症发生。成功再通组35例（38.5%）采用自膨式支架，56例（61.5%）患者采用球扩式 支架，自膨式支架组和球扩式支架组术后中位残余狭窄率分别为10.0%（10.0%～16.3%）和10.0% （5.0%～10.0%），差异无统计学意义。成功再通组中有85例（93.4%）完成术后3个月到1年的随访并进 行了CTA或DSA检查，随访中位时间为13.0（6.0～15.0）个月，术后再狭窄5例（5.9%），无术后再狭窄 80例（94.1%），术后再狭窄组较无术后再狭窄组的中位年龄更高（64.0岁 vs 59.5岁，P =0.027）。 结论 血管内再通治疗是治疗慢性锁骨下动脉闭塞的一种安全有效的方法。