Subclavian Artery Disease: Diagnosis and Therapy

Early Detection and One-Year Follow-Up of Subclavian Steal Syndrome Treated With Traditional Chinese Medicine: A Case Report

Subclavian steal syndrome (SSS) often goes undiagnosed because of its variable and subtle symptoms, highlighting the need for innovative diagnostic approaches. This case report explores the integration of traditional Chinese medicine (TCM) in both diagnosing and managing SSS, marking a pioneering contribution to the field. An 80-year-old woman with persistent dizziness, unresponsive to conventional treatments, underwent TCM pulse diagnosis, which revealed significant inter-arm pulse discrepancies. Subsequent Western imaging confirmed SSS. The patient was treated with Chinese herbal medicines (CHMs) targeting Qi deficiency and blood stasis, resulting in significant symptom improvement and a reduction in inter-arm systolic blood pressure disparities. Follow-up over 1 year showed sustained benefits. The integration of TCM pulse diagnosis, CHMs, and Western imaging highlights their complementary roles and potential as adjunctive therapies for managing SSS, offering a novel and comprehensive therapeutic strategy.

Stenting for subclavian steal phenomenon to restore cerebral perfusion due to acute carotid occlusion following carotid endarterectomy: a case report

BACKGROUND

Perioperative symptomatic carotid artery occlusion after carotid endarterectomy is a rare complication. In this study, we present a case of symptomatic acute carotid artery occlusion that occurred after carotid endarterectomy in a patient with coexistent subclavian artery steal phenomenon, which was successfully treated with subclavian artery stenting.

CASE PRESENTATION

A 57-year-old East Asian female presented with stenosis in the left common carotid artery and left subclavian artery along with subclavian steal. The proximal segment of the left anterior cerebral artery was hypoplastic, and the posterior communicating arteries on both sides were well-developed. Left internal carotid artery stenosis progressed during the follow-up examination; therefore, left carotid endarterectomy was performed. On the following day, symptoms of cerebral perfusion deficiency appeared due to occlusion of the left carotid artery. The stenotic origin of the left common carotid artery and the suspected massive thrombus in the left carotid artery posed challenges to carotid revascularization. Therefore, left subclavian artery stenting for the subclavian steal phenomenon was determined to be the best option for restoring cerebral blood flow to the whole brain. Her symptoms improved after the procedure, and the postprocedural workup revealed improved cerebral blood flow.

CONCLUSION

Subclavian artery stenting is safe and may be helpful in patients with cerebral perfusion deficiency caused by intractable acute carotid occlusion coexisting with the subclavian steal phenomenon. Revascularization of asymptomatic subclavian artery stenosis is generally not recommended. However, cerebral circulatory insufficiency as a comorbidity may be worth considering.

Endovascular Treatment for Subclavian Artery Stenosis and Occlusion: A Single-Center Retrospective Study

BACKGROUND

Subclavian artery stenosis and occlusion are common arterial diseases in the upper extremities, with atherosclerosis being the main cause. Endovascular treatment has emerged as a promising alternative to open surgical repair, but data are limited. This study aimed to evaluate the safety and effectiveness of endovascular procedures in the treatment of subclavian artery lesions at a tertiary vascular center in Vietnam.

METHODS

A retrospective analysis was conducted on patients who underwent endovascular treatment for symptomatic subclavian artery stenosis or occlusion between October 2013 and April 2022. Clinical characteristics, procedural details, short- and long-term outcomes, and patency rates were assessed.

RESULTS

Twenty-five patients were included in the study, with a mean age of 56.8 years. The majority of patients had risk factors for atherosclerosis, and all presented with symptoms related to subclavian artery disease. The endovascular procedures were successful in 96% of cases, with a low complication rate of 8%. During a median follow-up of 43 months, the overall patency rate was 92% at three years.

CONCLUSION

Endovascular treatment of subclavian artery stenosis and occlusion is a safe and effective option, with excellent long-term patency rates. These findings support the use of percutaneous revascularization as the first-line therapy, particularly in experienced centers. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.

Cardiac and Vascular Causes of Syncope and Atherosclerosis

PURPOSE OF REVIEW

Among the most common causes of cardiac syncope are arrhythmias and ischemic heart disease, both of which can coexist. The purpose of this review is to discuss the main causes of cardiac and vascular syncope related to atherosclerosis, its epidemiological and clinical aspects, warning signs, and initial approach.

RECENT FINDINGS

Cardiac syncope may have a frequency of up to 34% in elderly people. Atherosclerosis-related causes of cardiac and vascular syncope may be due to cardiac arrhythmia and/or structural impairment of the heart or arteries. Late ventricular tachycardia and late-onset high-grade atrioventricular block associated with myocardial ischemia may occur with syncope, which is related to higher mortality. Besides ventricular dysfunction, concentric remodeling is also a prognostic factor. In calcific degenerative aortic stenosis, syncope carries a worse prognosis than the other cardinal signs. Cardiac syncope has a high recurrence and mortality rate. There are red flag alerts that must be considered in risk stratification.

Subclavian Artery Calcification: A Narrative Review

Subclavian artery calcification (SAC) affects 2% of the population and presents a serious risk of developing into subclavian steal syndrome (SSS). Risk factors for plaque formation of the subclavian artery include diabetes, hypertension, and smoking. While SAC generally presents as asymptomatic, symptoms in severe cases may include numbness, pain at rest, and ischemic gangrene. Patients with severe SSS are at high risk of developing neurological symptoms as a result of vertebrobasilar insufficiency affecting posterior cerebral perfusion. On physical examination, SSS is preliminarily diagnosed from bilateral inter-arm systolic blood pressure discrepancy (>10 mmHg), which can be further confirmed with vascular imaging. Duplex ultrasound (DUS) is a cost-effective and non-invasive baseline technique for visualizing luminal stenosis and quantifying peak systolic velocity (PSV). Computed tomography angiography (CTA) provides high-quality, fast, three-dimensional (3D) imaging at the cost of introducing nephrotoxic contrast agents. Magnetic resonance angiography (MRA) is the safest 3D imaging modality, without the use of X-rays and contrast agents, that is useful in assessing plaque characteristics and degree of stenosis. DUS-assisted digital subtraction angiography (DSA) remains the gold standard for grading the degree of stenosis in the subclavian artery and determining the distance between the puncture site and lesion, which can be carried out in a combined procedure with endovascular management strategies. The fundamental treatment options are surgical and endovascular intervention. Endovascular treatment options include percutaneous transluminal angiography (PTA) for recanalization of the stenosed vessel and permanent balloon stenting to prevent collapse after PTA. Overall, the benefits of endovascular management encompass faster recovery, lower stenosis recurrence rate, and lower incidence of complications, making it the treatment of choice in low-risk patients. Surgical interventions, although more complex, are considered gold-standard treatment options.

Color Doppler Ultrasonography for the Evaluation of Subclavian Artery Stenosis

BACKGROUND

It is of great significance to evaluate symptomatic subclavian artery (SA) stenosis by color Doppler ultrasonography. More than 50% SA stenosis may induce symptoms. Currently, there is a paucity of published literature and lack of practitioner consensus for how ultrasonic findings should be interpreted in patients with SA stenosis.

OBJECTIVE

The study aimed to prospectively evaluate SA stenosis using color Doppler ultrasonography, with digital subtraction angiography as a reference. Moreover, we aimed to determine the optimal thresholds to predict SA stenosis (≥50%).

METHODS

A total of 423 SAs from 234 patients with normal or stenotic lumen were enrolled. The peak systolic velocity (PSV) and acceleration time at the stenotic and distal segments of the SA, peak reversed velocity of the vertebral artery, and waveforms of the stenotic SA, distal SA, and vertebral artery were recorded. The ratios of stenotic PSV to distal PSV (PSVr) and distal AT to stenotic AT were also calculated. The optimal cutoff values were determined using receiver operating characteristic analysis.

RESULTS

All ultrasonic parameters were significantly correlated with the degree of SA stenosis, whereas PSV (r = 0.624, P < 0.001), PSVr (r = 0.654, P < 0.001) and VA waveform change (r = 0.631, P < 0.001) had the strongest correlation with SA stenosis. The optimal cutoff values were as follows: PSV ≥ 230 cm/s and PSVr ≥ 2.2 to predict ≥ 50% stenosis, and PSV ≥ 340 cm/s and PSVr ≥ 3.0 to predict ≥ 70% stenosis.

CONCLUSIONS

Symptomatic patients with the ultrasonic parameters of PSV ≥ 230 cm/s and PSVr ≥ 2.2 need to be considered for further verification by computed tomographic angiography or magnetic resonance angiography, or by digital subtraction angiography with a view to percutaneous transluminal angioplasty/stent implantation in the same session. The recommended graded cutoff values can help in long-term management of patients with SA stenosis.

"Asymptomatic" Subclavian Steal Syndrome

The definition of subclavian steal is subclavian artery occlusion or hemodynamically significant stenosis proximal to the origin of the vertebral artery that results in lower pressure in the distal subclavian artery. Although subclavian steal can often remain asymptomatic, if ignored, it can cause syncope or neurological deficits. Detailed routine evaluation of blood pressure and careful physical examination, simultaneously on both sides of patients at high vascular risk (such as those with hypertension, dyslipidemia, and diabetes), can assist in the early detection. Herein, we report the case of an 82-year-old male patient with steal syndrome, who had no subjective symptoms despite severe stenosis of the subclavian artery, with a marked left-right difference in blood pressure.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery

BACKGROUND/PURPOSE

The therapeutic efficacy of percutaneous transluminal angioplasty and stenting (PTAS) of post-irradiated stenosis of subclavian artery (PISSA) was not well clarified. This retrospective study was designed to evaluate the technical safety and outcome of the patients of severe symptomatic PISSA accepted PTAS.

METHODS

Between 2000 and 2019, 16 cases with 17 lesions of symptomatic and medically refractory PISSA accepted PTAS were included. We evaluated their technical success, peri-procedural complications and diffusion-weight imaging (DWI) of brain magnetic resonance imaging (MRI), results of symptom relief, and long-term stent patency.

RESULTS

The stenosis of the 17 stenotic lesions were 81.2 ± 11.1%. The most common symptom of the 16 patients was dizziness (14/16, 87.5%). All successfully accepted PTAS without neurological complication and had symptom relief after PTAS (17/17, 100%). Of the 12 patients accepted pre-procedural and early post-procedural MRI follow-up, 2 patients had an asymptomatic tiny acute embolic infarct in the territory of vertebrobasilar system. In a 51.9 ± 54.9 months follow-up, all patients had no severe restenosis and no recurrent vertebrobasilar ischemic symptoms.

CONCLUSION

For patients with PISSA and medically refractory ischemic symptoms, PTAS can be an effective alternative management.

Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy

The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.

[Detection of peripheral artery disease in patients with ischemic heart disease. A quick guide for medical practitioners]

In this manual, the authors focused on the principal methods for diagnosis of peripheral artery disease in cardiological patients, from the interview and physical examination to functional tests and vascular visualization. Diagnostic and prognostic value of each method, its potentialities for reducing the risk of cardiovascular events (CVE), including myocardial infarction (MI), ischemic stroke (IS) or extremity amputation in critical ischemia, and overall mortality are discussed. The authors provided current information about a possibility of reducing the risk of CVE by intensifying the antithrombotic therapy according to results of the COMPASS study.

Acute coronary syndrome following arteriovenous fistula creation in a post CABG patient: A steal phenomenon from coronary artery to subclavian artery

A 70-year-old man with a history of coronary artery bypass grafting 15 years back and arteriovenous (AV) fistula creation in the left arm 1 month back presented with acute coronary syndrome (ACS). He had not received dialysis before his referral. We felt the most likely etiology for these complaints was increased cardiac oxygen demand from an increased cardiac output related to the newly formed left AV fistula. Coronary angiography was done to detect any significant stenosis in the native or grafted vessels. This revealed that the left subclavian artery was totally occluded in the ostioproximal segment and the coronary arteries did not have occlusions to explain the ACS setting. CT angiography confirmed the angiographic findings of the totally occluded left subclavian artery followed by a well-developed and patent left internal mammary artery to left anterior descending artery. This led to the consideration of a steal syndrome from the coronary artery by the subclavian artery distal to the occlusion. A successful percutaneous endovascular intervention on the left subclavian artery occlusion was performed. Subsequently, the patient became asymptomatic and experienced a dramatic increase in left ventricular ejection fraction.

An Interesting Case of a Cold Left Arm

Inter-arm variability in blood pressure readings typically signifies arterial disease between the aortic arch and the subclavian artery. The differential diagnosis includes thoracic aortic dissection, atherosclerosis, thoracic outlet syndrome, and subclavian artery stenosis and thrombosis. In patients with prior coronary artery bypass grafting, including the internal mammary artery, several of those conditions can compromise coronary blood flow and lead to myocardial ischemia. Here we discuss a case of left subclavian artery thrombosis, which compromised left internal mammary artery blood flow and led to ischemic ventricular tachycardia.

Systolic murmur in disguise: subclavian artery stenosis as an overlooked cause of missed case of hypertension

In this report we present a case of missed hypertension due to subclavian artery stenosis. A 77 year-old female patient, initially thought as being normotensive, was referred to us due to newly discovered systolic heart murmur suspicious for aortic stenosis. We noted inter-arm blood pressure difference of 30 mmHg, with higher, hypertensive values on right arm. Further workup and medical imaging excluded aortic stenosis and revealed an asymptomatic, hemodynamically significant, stenosis of left subclavian artery. Due to absence of symptoms, the patient has been managed with conservative therapy for subclavian stenosis and hypertension, and she is currently in good conditions and followed up for any signs of disease progression. This case clearly shows importance of measuring blood pressure on both arms when initially diagnosing hypertension as this is often overlooked and is key to properly diagnose hypertension and possible subclavian stenosis.

Significance of hemodynamic assessment by pressure wire for endovascular therapy of subclavian steal syndrome

OBJECTIVE

Subclavian steal syndrome results from hemodynamic impairment due to stenosis or occlusion of subclavian artery. Therefore, it is important for subclavian steal syndrome patients to assess hemodynamic status during endovascular therapy.

METHODS

Eleven subclavian steal syndrome patients undergoing endovascular therapy attended this study. Pressure wire was used to measure trans-stenosis pressure difference (ΔP). Digital subtraction angiography, Transcranial Doppler and Electronic sphygmomanometer were introduced to assess stenotic rate, steal grade and inter-arm systolic pressure difference, respectively. Clinical symptoms and restenosis were followed up after endovascular therapy. The associations of ΔP with stenotic rate, inter-arm pressure difference, steal degree, clinic symptoms and restenosis were analyzed in this paper.

RESULTS

Prior to the therapy, ΔP moderately correlated with stenotic rate (r = 0.757, p = 0.007) and inter-arm pressure difference (r = 0.701, p = 0.016). ΔP was ≥6 mmHg in all patients, and 6-9 mmHg for grade 1 steal and ≥10 mmHg for grade 2 and 3 steals. After the therapy, all patients had technique success, and 10 patients had clinic success, and 1 patient appeared restenosis. ΔP was ≤3 mmHg and steal disappeared in the patients with clinical success. ΔP was 18 mmHg and grade 3 steal still existed in one patient without clinical success. One patient with 1 mmHg of ΔP after therapy appeared restenosis in the follow-up.

CONCLUSION

The trans-stenosis pressure difference is closely related to steal degree and clinical symptoms. The measurement of hemodynamic status by pressure wire is very useful to guide endovascular therapy in subclavian steal syndrome patients. However, the restenosis may still occur, even though the hemodynamic impairment is improved.

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.

Pseudo-hypotension with acute pulmonary oedema due to simultaneous bilateral subclavian artery stenosis in a patient with coronary artery bypass graft surgery using bilateral internal mammary arteries: a case report

A 75-year-old woman, with a history of bilateral internal mammary artery-coronary artery bypass graft surgery, developed hypotension and pulmonary oedema posing as cardiogenic shock. Severe bilateral subclavian artery stenosis emerged to be the cause of ischaemic myocardial dysfunction and heart failure. An emergency endovascular treatment was successfully performed. The presence of simultaneous bilateral subclavian artery narrowing as the pathophysiologic mechanism of myocardial ischaemia makes this case remarkable.

Stem Cell Therapies in Peripheral Vascular Diseases — Current Status

Peripheral artery diseases include all arterial diseases with the exception of coronary and aortic involvement, more specifically diseases of the extracranial carotids, upper limb arteries, mesenteric and renal vessels, and last but not least, lower limb arteries. Mononuclear stem cells, harvested from various sites (bone marrow, peripheral blood, mesenchymal cells, adipose-derived stem cells) have been studied as a treatment option for alleviating symptoms in peripheral artery disease, as potential stimulators for therapeutic angiogenesis, thus improving vascularization of the ischemic tissue. The aim of this manuscript was to review current medical literature on a novel treatment method — cell therapy, in patients with various peripheral vascular diseases, including carotid, renal, mesenteric artery disease, thromboangiitis obliterans, as well as upper and lower limb artery disease.

A case of sudden death due to spontaneous right subclavian artery dissection

Acute subclavian artery dissection (SAD) is a rare entity which is usually associated with several vascular abnormalities and traumatic events. Spontaneous SAD remains exceptional and often affects the left artery. We report the autopsy case of a 29-year-old female who died suddenly following a spontaneous dissection of the right subclavian artery.