Subclavian steal and rest pain in a case of brachiocephalic artery occlusion

A patient with multiple vessel disease presented with symptoms of significant bilateral upper extremity pain and weakness that was more significant on the right side. On carotid duplex scanning, brachiocephalic artery occlusion with retrograde flow was noted through the right common carotid and right vertebral arteries at rest. Furthermore, 50% to 90% occlusion of the left internal carotid was noted. Filling of the right subclavian artery was noted to be through the right vertebral and right common carotid arteries. Unlike isolated subclavian steal syndrome, brachiocephalic artery occlusion induces significant hemodynamic alterations in extracranial arterial flow, which normally produces no symptoms at rest, but may produce symptoms with exercise. The occurrence of subclavian steal phenomenon in the presence of brachiocephalic occlusion is extremely rare. The present case is the first to report a patient presenting with bilateral upper extremity rest pain in the presence of brachiocephalic artery occlusive disease.     

Right-sided aorta with atypical coarctation involving only the left subclavian artery. Hypertension

A case has been described of right-sided aorta with coarctation of the left subclavian artery. The diagnosis was made clinically and by ordinary x-ray film and then confirmed by angiocardiographic films.A small or absent left radial pulse in the presence of a hypertension in the right arm and a normal expected blood pressure in the lower extremities should lead to the consideration of the diagnosis of a localized coarctation of the left subclavian artery. Such causes as cervical rib, anomalous course of the left radial artery, tumors, and aortic aneurysm must first be investigated.With a localized coarctation of the left subclavian artery, just as with the typical coarctation of the aorta, a hypertension is usually present. It is probably a reflex mechanism originating from the nerves in the aortic arch and producing an increased vascular tone in all the extremities.Localized coarctation of the left subclavian artery frequently is discovered by accident. The patient presents no anatomic or physiologic defect in the left upper extremity except the small or absent left radial pulse. Hard work is quite compatible with the lesion.     

A case of tuberculous aneurysm of subclavian artery occurred in the course of treatment for miliary tuberculosis

This case is a 56-year old woman. Steroids were being administered perorally after a thymectomy for myasthenia gravis. A fever of 38-39 degrees Celsius appeared during night, an abnormal shadow showed up on a chest X-ray and the patient was hospitalized. Gaffky No. 2 acid-fast bacilli were detected in the patient's sputum and the chest CT showed diffuse granular-like shadow, the patient was diagnosed as miliary tuberculosis and treatment with combined use of INH, RFP, EB, and PZA was started. Subsequently, fever started to subside and the miliary shadow on chest X-ray improved, however, six weeks after the start of treatment, hoarseness and dysphagia appeared. From the cervical CT and cervical angiography findings, the diagnosis of right subclavian artery impending ruptured aneurysm was made. Because the patient's sputum was acid-fast bacilli positive and because the patient had undergone thymectomy, it was decided that it would be difficult to treat her by a thoracotomy again. Therefore, a right subclavian artery stent insertion, right subclavian artery-right common carotid artery bypass creation operation was carried out with the objective of blocking the flow of blood to the aneurysm. The hoarseness and dysphagia improved post-operatively and the patient's progress is being monitored. Tuberculous aneurysms are a rare affection and they are mostly discovered when the autopsy is done, however, this case was diagnosed due to the manifestation of subjective symptoms. While this case was not diagnosed histopathologically, it is envisaged from the clinical progress that this was a tuberculous subclavian aneurysm complicated during the treatment for miliary tuberculosis.     

Anomalous right subclavian artery aneurysms. Report of 3 cases, with a review of the literature

During the past 2 years, 3 anomalous right subclavian artery aneurysms have been encountered at the St. Louis Heart Institute. The 1st patient, a 72-year-old woman, was found to have an asymptomatic 5-cm-diameter anomalous right subclavian artery aneurysm after surgery for suspected rupture of an abdominal aortic aneurysm. Resection was not attempted because of her poor cardiopulmonary and renal condition. One year later, the patient remains alive with marked cardiopulmonary limitations. The 2nd patient, a 77-year-old man, experienced dysphagia and severe weight loss because of a 14-cm-diameter aneurysm. Three days after undergoing surgical repair, he required reoperation for graft occlusion with right upper-extremity ischemia. Six months after hospital discharge, he died of pulmonary insufficiency and metastatic colon cancer. The 3rd patient, a 73-year-old woman, required emergency surgical intervention because of acute rupture and hypovolemic shock. Thirteen days later, she died of aspiration, asphyxia, and cardiac arrest. On the basis of our experience and a review of the literature, we conclude that symptomatic anomalous right subclavian artery aneurysms are rare, and that surgical intervention entails a relatively high morbidity and mortality rate. If long-term survival is anticipated, associated medical illnesses should be considered before surgery is undertaken.     

Aneurysms of an aberrant right subclavian artery: report of two cases

Aneurysm of the aberrant right subclavian artery is rare. We report two patients who underwent successful repair using hypothermic circulatory arrest and retrograde cerebral perfusion. One patient presented with progressive dysphagia to solids and hoarseness of voice due to pressure exerted by the expanding aneurysm, and the second patient, with a dissected subclavian aneurysm, presented with transient ischaemic attacks and a previous cerebral infarct secondary to embolism. Repair in both patients was done through a median sternotomy with femoral arterial and right atrial venous cannulation. Under hypothermic circulatory arrest, the origin of the subclavian aneurysm was divided off the aorta and closed with a Dacron patch from outside the aorta in one patient, and from within the aorta in the other patient. Concomitant revascularisation of the right upper limb was achieved using a 12-mm Hemishield Dacron graft from the ascending aorta to the distal right subclavian artery. The graft to subclavian anastomosis was done under hypothermic circulatory arrest as distal control was not possible. The graft to the aortic anastomosis was done over a side-biting clamp during rewarming. Both patients were successfully treated without major morbidity.     

Thoracic Endovascular Aortic Repair With Subclavian Revascularization for Symptomatic Nonaneurysmal Aberrant Right Subclavian Artery

Aberrant right subclavian artery is a common aortic arch anomaly that can cause dysphagia as a result of compression by the aberrant artery. For patients with an aneurysm associated with an aberrant right subclavian artery, surgical or endovascular intervention is a well-described treatment. However, for patients with a nonaneurysmal aberrant right subclavian artery, treatment with thoracic endovascular aortic repair has been limited. We describe the use of thoracic endovascular aortic repair and subclavian revascularization to treat esophageal stricture in a patient with a symptomatic nonaneurysmal aberrant right subclavian artery. The patient''s dysphagia was successfully relieved after the operation.     

Subclavian-coronary steal syndrome following CABG--a case report

A case of 47-year-old man with occlusion of the subclavian artery occurring few months after CABG with the left internal mammary artery grafting is presented. The patient developed a subclavian-coronary steal syndrome with retrograde blood flow from the coronary circulation to the subclavian artery through the left internal mammary artery. Clinical presentation consisted of vertigo and recurrence of chest pain. The increasing frequency of this syndrome and the preoperative preventive methods such as pressure gradient measurement between the left and right upper limb are discussed.     

Aneurysm of an aberrant right subclavian artery. Report of a surgically treated case

A 53-year-old man was admitted for treatment of an aberrant right subclavian artery aneurysm that had been diagnosed 5 years earlier and had recently begun to enlarge. The aneurysm, which involved the right subclavian artery from its origin, measured 47 mm in diameter and about 10 cm in length. Because of the lesion's size and friability, a 2-stage operation was performed. In the 1st stage, the right subclavian and right vertebral arteries were revascularized with double bypass grafts via a right cervical approach. In the 2nd stage, the patient was repositioned and a left thoracotomy incision was made. With the aid of left-heart bypass, the aorta was cross-clamped proximal and distal to the lesion, and the aneurysmal orifice was closed with a Dacron patch. The patient was discharged from the hospital on the 17th postoperative day and remains asymptomatic 24 months later. We recommend the 2-stage technique for similar cases because it prevents limb ischemia and reduces the risk of hemorrhagic and embolic complications.     

Refractory rapidly progressive Takayasu’s arteritis successfully treated with surgery

We describe a case of a patient with rapidly progressive Takayasu’s arteritis (TA) refractory to conventional immunosuppressive therapy in whom bypass surgery was successfully performed. A 38-year-old woman had 2 years history of symptoms of compromised cerebral circulation, severe claudication of upper and lower limbs and stenocardial symptoms. Serial arteriography revealed occlusions of the right subclavian and right common iliac arteries and later on stenosis of the abdominal aorta and complete obliteration of the left subclavian artery. Coronarography did not show coronary stenosis. Completely occluded left subclavian artery resulted in a characteristic subclavian steal syndrome. Therapy with combined immunosuppressants was ineffective, severe ischaemic symptoms related to arterial occlusions progressed and surgical intervention was inevitable. She underwent aorto–bifemoral and 10 months later left carotid-axillary bypass grafting. The ischaemic symptoms were resolved after surgery. At 3 years follow-up, the patient remained asymptomatic with no evidence of restenosis. This case indicates that patients with progressive TA with no improvement while on conventional immunosuppressive therapy could have satisfactory outcome and excellent long-term clinical remission after multiple arterial bypass grafting.     

Complete revascularization of total obstruction of both subclavian arteries and descending abdominal aorta by combined surgery and percutaneous transluminal angioplasty

A 48-year-old man was admitted with chest pain, intermittent claudication and right upper extremity weakness. Magnetic resonance angiography revealed total occlusion of both subclavian arteries and descending abdominal aorta below renal artery. End-to-side aorta to bifemoral graft surgery and percutaneous transluminal angioplasty of both subclavian arteries were performed. Follow-up angiography after 6 months revealed patent left subclavian artery but 70% occluded right subclavian artery. Therefore re-intervention was performed at right subclavian artery.     

Subclavian Steal Phenomenon Associated With Vascular Ring in an Infant Who Had a Prenatally Diagnosed Right Aortic Arch With an Atretic Aberrant Left Subclavian Artery

Vascular ring is a rare congenital anomaly in which the abnormal origin of the aorta or its branches and pulmonary arteries leads to encircling and compression of the trachea and esophagus. A right aortic arch (RAA) with an aberrant left subclavian artery is one of the most common forms of vascular ring. Here, we report a case of a prenatally diagnosed vascular ring resulting from an RAA with an aberrant left subclavian artery. When the infant was 7 months of age, the development of noisy breathing prompted further evaluation with cardiac magnetic resonance imaging that showed an atretic left subclavian artery associated with collateral retrograde flow from the left vertebral artery to the distal portion of the subclavian artery. Our findings indicate that an untreated RAA with an aberrant left subclavian artery may be associated with an increased risk of developing subclavian artery steal syndrome.     

Renal artery aneurysm treatment with coil embolization.

Renal artery aneurysm is a rare condition, but its incidence has increased through discovery because of improved imaging techniques. However, a therapeutic approach for renal artery aneurysm has not been established. We report the case of a 58-year-old female who had developed hypertension at 52 years of age and was under oral medication for this condition. In a medical check-up, a right renal artery aneurysm of 10 mm in diameter was detected by computed tomography (CT). Renal function was normal and there were no abnormalities in urinalysis; therefore, the patient was observed as an outpatient. Abdominal CT performed 9 months later revealed a saccular renal artery aneurysm of 15 mm in diameter with partial wall calcification and mild mural thrombus. Selective right renal arteriography detected a tumor with calcification, but no renal arterial stenosis or renal arteriovenous fistula. Since the aneurysm had enlarged, catheter treatment was selected to reduce the risk of rupture. A 6-Fr guide catheter was inserted into the right renal artery and the tip of a microcoil catheter was advanced into the aneurysm, which was then embolized with 12 microcoils. The absence of the aneurysm was confirmed using right renal arteriography. No complications occurred during or after embolization, and selective right renal arteriography performed 3 months later showed no change in the coil position or blood flow in the aneurysm, suggesting a good postoperative course. Our results suggest that this approach may generally be applicable for renal artery aneurysms, depending on the shape, size, and location of the aneurysm.     

Acute thrombosis of subclavian artery during CPR

The case of a 73-year-old man who developed acute thrombosis of the left subclavian artery during CPR is presented. The patient was known to have severe chronic obstructive lung disease, hypertension, coronary artery disease, and severe peripheral vascular disease. He was admitted with ventricular fibrillation. CPR was successful, and the ECG revealed acute extensive anterior and recurrent inferior wall myocardial infarctions. Soon after, acute occlusion of the left subclavian artery was diagnosed. Thrombectomy was performed and circulation was restored to the left upper limb. The patient died 12 hours later from severe bradycardia and asystole.     

Chronic dissection of the left subclavian artery with pseudocoarctation

Surgical management of a dissection of the subclavian artery is sparsely reported in the literature because of its rare occurrence. Recently, we treated a patient who had presented with a huge left subclavian artery dissection, a small right subclavian artery aneurysm with pseudocoarctation of the aorta, and a small perimembranous ventricular septal defect. Surgical management of the left subclavian artery dissection and correction of the pseudocoarctation of the aorta were achieved effectively. That unusual combination of pathologic conditions prompted us to report this case.     

介入治疗右侧锁骨下动脉盗血综合征

目的探讨介入治疗右侧锁骨下动脉盗血综合征的特点和疗效。方法回顾分析11例右侧锁骨下动脉盗血综合征患者行血管内介入治疗的临床资料。结果 11例右侧锁骨下动脉盗血综合征患者成功置入支架,术后锁骨下动脉残余狭窄小于20%,盗血现象消失,椎-基底动脉供血不足症状消失。随访1年未发现再狭窄。结论重视右锁骨下动脉狭窄和闭塞的特殊性和复杂性,仔细了解右侧锁骨下动脉结构特点,做好手术预案是取得介入治疗成功的必要条件。     

Multiple pulmonary emboli with pulmonary hypertension caused by effort thrombosis and effective balloon venoplasty of the subclavian vein

A 36-year-old woman with effort thrombosis of the subclavian vein associated with multiple pulmonary emboli was successfully treated with local thrombolysis of the subclavian vein using a pulse-spray catheter and systemic anticoagulation. Balloon venoplasty of the residual stenosis of subclavian vein was carried out and in follow-up venography 6 months later, there was no restenosis, and the patient has been asymptomatic for 12 months. Pulmonary embolism is not a rare complication of upper extremity deep vein thrombosis and should be managed as aggressively as lower extremity deep vein thrombosis.     

Hybrid Repair of an Aberrant Right Subclavian Artery with Kommerell's Diverticulum

This publication describes a hybrid endovascular and open surgical approach to treating a large aneurysm of an aberrant right subclavian artery (Kommerell's diverticulum). A 76-year old man presented with dysphagia lusoria due to a 3.5 × 3.0 cm aneurysm involving an aberrant right subclavian artery. The patient was treated by a thoracic aortic endograft, left subclavian artery de-branching (by its transposition to the left common carotid artery) and right subclavian artery revascularisation. This approach avoids the requirement for a thoracotomy or sternotomy needed with open surgical repair. At a 6 months follow-up assessment the aneurysm was shown to be thrombosed with no evidence of endoleak.     

Stridor and Horner's syndrome, weeks after attempted right subclavian vein cannulation

A 23-year-old woman presented with renal failure resulting from polycystic kidney disease (PKD) aggravated by tubulo-interstitial nephritis. Emergency haemodialysis was planned, and cannulation of the right subclavian vein was attempted, but failed. During this procedure, inadvertent arterial puncture occurred. Transient mild ischaemia of the right arm, and a transient Horner's syndrome were noted. Seven weeks later she presented with severe stridor with impending respiratory failure necessitating emergency intubation; the right-sided Horner's syndrome had recurred. CT imaging showed a large pseudo-aneurysm of the brachiocephalic artery resulting in severe compression of the trachea. Using a prosthetic graft, the operation for the pseudo-aneurysm was successful; there were mild neurological sequelae. Although her family history was negative, autosomal dominant PKD should be considered, and we discuss the possible role of a pre-existing PKD-associated aneurysm.     

Repair of left subclavian artery and aberrant right subclavian artery aneurysms

Left subclavian artery aneurysm with an aneurysm of the aberrant right subclavian artery is a rare condition with a reported incidence of 0.13% to 1%. We report the successful surgical correction of both conditions in a 34-year-old man.     

True aneurysm originating from the costocervical trunk: surgical excision for recurrence after successful proximal coil embolization

A rare, true aneurysm of a branch of the right subclavian artery is described. Transcatheter coil embolization of the feeder artery was successful in obliterating blood flow into the aneurysm and the mass reduced in size. However, the aneurysm reenlarged over the next week of follow-up due to development and enlargement of the collateral vascular network. Extirpation of the aneurysm was performed. Histopathological examination revealed a true aneurysm. Received: July 30, 2001 / Accepted: September 22, 2001