{"id":573,"date":"2013-05-09T20:16:05","date_gmt":"2013-05-10T01:16:05","guid":{"rendered":"http:\/\/www.medradclinics.com\/\/?p=573"},"modified":"2016-06-23T02:52:57","modified_gmt":"2016-06-23T07:52:57","slug":"left-subclavian-vertebral-steal-syndrome-ken-ekechukwu-md-mph-facp","status":"publish","type":"post","link":"https:\/\/www.medradclinics.com\/?p=573","title":{"rendered":"Left subclavian-vertebral steal syndrome. | Ken Ekechukwu, MD, MPH, FACP"},"content":{"rendered":"

\"PSxxx7724_LSCAstenosis_beforestenting\"\u00a0<\/span>\"PSxxx7724_LSCAstenosis_beforestenting_reversedimage\"
\n\u00a0<\/span>\"PSxxx7724_LSCAstenosis_duringstenting\"\"PSxxx7724<\/p>\n

Key: LVA, left vertebral artery;\u00a0LSCA, left subclavian artery; LCCA, left common carotid artery; LIMA, left internal mammry artery<\/span><\/h6>\n

The vertebral artery is the first branch\u00a0of the\u00a0subclavian artery\u00a0and\u00a0supplies the hindbrain, while the internal mammary artery is its second branch and courses behind the\u00a0anterior chest wall\u00a0to anastomose with the ipsilateral inferior epigastric artery in the rectus sheath; it offers a nautural route for lower body perfusion in obstructive diseases of the thoracic aorta or\u00a0is\u00a0grafted to a coronary artery in coronary artery bypass interventions (left internal mammary artery). In\u00a0most people the left\u00a0subclavian artery arises from the posterior aortic arch, while the right subclavian artery arises from the brachiocephalic trunk, itself the first branch of the aortic arch. A patient may\u00a0develop\u00a0vertebrobasilar insufficiency\u00a0due\u00a0stenosis or occlusion of the brachiocephalic or subclavian artery,\u00a0called vertebral-subclavian syndrome. Similarly, symptoms of coronary hypoperfusion may develop in those in whom\u00a0their left internal mammary artery (LIMA) is grafted to a coronary artery for\u00a0coronary bypass surgery.<\/span><\/p>\n

\u00a0In vertebral-subclavian steal syndrome, because the increased demand for blood that attends active use of an upper extremity is not met due to critical stenosis or occlusion of the brachiocephalic trunk or the subclavian artery, blood is short-circuted from the ipsilateral vertebral artery reducing hindbrain perfusion. The patient may\u00a0experience such hindbrain symptoms as dizziness, nausea, dyequilibrium and vomiting that improve by resting the limb. Similarly, in coronary-subclavian syndrome blood is shunted from the coronary artery to which the LIMA is grafted, causing coronary syndrome involving the short-changed myocardial territory that improves with resting the left upper limb.<\/span><\/p>\n

The commonest cause of large-vessel obstruction in the upper extremities is atherosclerosis and the left subclavian artery is affected by stenotic\/occlusive disease 8 to 10 times more than the\u00a0right subclavian artery. In the past such disease was solely managed by surgery – direct reconstruction via endarterectomy or\u00a0aortic arch bypass – but with improved endovarscular techniques,\u00a0\u00a0it is increasingly addressed endovascularly. Although few studies have compared endovascular stent-supported subclavian revascularization with aortic bypass interventions, the initial clinical success of the former is seen in nearly 100% of stenotic lesions and 60% to 100% of occlusions. Primary patency at 1 year\u00a0has been reported in 91% to 100%, dropping to 82% to 86% at 3 years and 77% at 5 years.<\/span><\/p>\n

\u00a0<\/span>The 4 images you see above were recorded by me during primary stenting of irregular atherosclerotic stenosis of the left subclavian artery in a 54-year-old hispanic female who was referred to my interventional radiology clinic for management of the stenosis. She had presented to her primary care physician with symptoms of hindbrain ischemia upon using her left upper limb and earlier workup confirmed\u00a0left subclavian arterial stenosis. The 2 top images illustrate the character and severity of her disease, the first image in the bottom row shows the process of balloon-expandable stenting of the disease, while the 2nd image in the bottom row reveals complete elimination of the stenosis and reappearance of the left vertebral and internal mammary arteires,\u00a0which were\u00a0invisible on the pre-intervention angiograms reflecting the severity of the stenosis.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

\u00a0 \u00a0 Key: LVA, left vertebral artery;\u00a0LSCA, left subclavian artery; LCCA, left common carotid artery; LIMA, left internal mammry artery The vertebral artery is the first branch\u00a0of the\u00a0subclavian artery\u00a0and\u00a0supplies the hindbrain, while the internal mammary artery is its second branch and courses behind the\u00a0anterior chest wall\u00a0to anastomose with the ipsilateral inferior epigastric artery in the […]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-573","post","type-post","status-publish","format-standard","hentry","category-uncategorized","pmpro-has-access"],"_links":{"self":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/573","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=573"}],"version-history":[{"count":9,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/573\/revisions"}],"predecessor-version":[{"id":2692,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=\/wp\/v2\/posts\/573\/revisions\/2692"}],"wp:attachment":[{"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=573"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=573"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.medradclinics.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=573"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}