Subclavian steal syndrome

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Subclavian steal syndrome Classification and external resources
ICD-10	G45.8
ICD-9	435.2
DiseasesDB	31525
MeSH	D013349

In medicine, subclavian steal syndrome (SSS), also subclavian steal phenomenon and subclavian steal steno-occlusive disease, is a constellation of signs and symptoms that arise from retrograde (reversed) vertebral artery (blood) flow or retrograde internal thoracic artery flow due to a proximal subclavian artery stenosis (narrowing) and/or occlusion.

Contents 1 Pathophysiology 1.1 Hemodynamics 1.2 Vascular anatomy 1.3 Path of the blood (normal versus SSS) 2 Etiology 3 Signs and symptoms 4 Differential diagnosis 5 Diagnostic tests 6 Treatment 7 See also 8 References 9 External links

[edit] Pathophysiology

Classically, SSS is a consequence of a redundancy in the circulation of the brain^[1][2] and the flow of blood.

SSS results when the short low resistance path (along the subclavian artery) becomes a high resistance path (due to narrowing) and blood flows around the narrowing via the arteries that supply the brain (left and right vertebral artery, left and right internal carotid artery). The blood flow from the brain to the upper limb in SSS is considered to be stolen as it is blood flow the brain must do without.

As in vertebral-subclavian steal, coronary-subclavian steal may occur in patients who have received a coronary artery bypass graft using the internal thoracic artery (ITA).^[3] As a result of this procedure, the distal end of the ITA is diverted to one of the coronary arteries (typically the LAD), facilitating blood supply to the heart. In the setting of increased resistance in the proximal subclavian artery, blood may flow backward away from the heart along the ITA causing myocardial ischemia. Vertebral-subclavian and coronary-subclavian steal can occur concurrently in patients with an ITA CABG.^[4]

[edit] Hemodynamics

Blood, like electrical current, flows along the path of least resistance. If blood is presented with two paths a short one that is very narrow (with a high overall resistance) and a long one that is wide (with a low overall resistance) it will take the long and wide path (the one with the lower resistance).

[edit] Vascular anatomy

The blood vessels supplying the brain arise from the vertebral arteries and internal carotid arteries and are connected to one another by communicating vessels that form a circle (known as the Circle of Willis).

[edit] Path of the blood (normal versus SSS)

Normally, blood flows from the aorta into the subclavian artery and then some of that blood leaves via the vertebral artery to supply the brain.

In SSS a reduced quantity of blood flows through the proximal subclavian artery. As a result, blood travels up one of the other blood vessels to the brain (the other vertebral or the carotids) goes around the cerebral arterial circle and via the (ipsilateral) vertebral artery to the subclavian (with the proximal blockage) and feeds blood to the distal subclavian artery (which supplies the upper limb and shoulder).

[edit] Etiology

• Atherosclerosis
• Cervical rib

[edit] Signs and symptoms

• Presyncope (sensation that one is about to faint)
• Syncope (fainting)
• Neurologic deficits
• Blood pressure differential between the arms

Associated with other stigma to vascular disease (e.g. vascular insufficiency ulcers of the foot).

[edit] Differential diagnosis

• Stroke

[edit] Diagnostic tests

• Doppler ultrasound
• CT angiography
• Angiogram

[edit] Treatment

• Stenting and balloon angioplasty
• Endartertectomy

[edit] See also

• Vascular access steal syndrome

[edit] References

1. ^ Klingelhöfer J, Conrad B, Benecke R, Frank B (1988). "Transcranial Doppler ultrasonography of carotid-basilar collateral circulation in subclavian steal.". Stroke 19 (8): 1036–42. PMID 3041649. 
2. ^ Lord R, Adar R, Stein R (1969). "Contribution of the circle of Willis to the subclavian steal syndrome.". Circulation 40 (6): 871–8. PMID 5377222. 
3. ^ Takach T, Reul G, Cooley D, Duncan J, Livesay J, Ott D, Gregoric I (2006). "Myocardial thievery: the coronary-subclavian steal syndrome.". Ann Thorac Surg 81 (1): 386–92. doi:10.1016/j.athoracsur.2005.05.071. PMID 16368420. 
4. ^ Lee S, Jeong M, Rhew J, Ahn Y, Na K, Song H, Bom H, Cho J, Ahn B, Park J, Kim S, Kang J (2003). "Simultaneous coronary - subclavian and vertebral - subclavian steal syndrome.". Circ J 67 (5): 464–6. doi:10.1253/circj.67.464. PMID 12736489. 

[edit] External links

• Subclavian Steal Syndrome - emedicine.com

v • d • e Cardiovascular disease: vascular disease - Circulatory system pathology (I60-I99, 430-459) Cerebrovascular diseases Intracranial hemorrhage: Extra-axial (Epidural, Subdural, Subarachnoid) - Cerebral/Intra-axial (Intraventricular, Intraparenchymal) Stroke/Brain ischemia: Vertebrobasilar insufficiency (Subclavian steal syndrome) - TIA Carotid artery stenosis - Cerebral aneurysm - Binswanger's disease - Moyamoya disease Anterior spinal artery syndrome Arteries, arterioles and capillaries Arterial occlusive disease: Arteriosclerosis (Atherosclerosis, Intermittent claudication, Atheroma) - Renal artery stenosis - Fibromuscular dysplasia - Degos disease Peripheral vascular disease: Raynaud's phenomenon/Raynaud's disease - Erythromelalgia Aneurysm (Aortic/Abdominal aortic) - Dissection (Aortic, Carotid, Vertebral) - Pseudoaneurysm Arteritis (Aortitis) - Buerger's disease Arteriovenous fistula - Hereditary hemorrhagic telangiectasia Nevus (Spider angioma) Veins Venous thrombosis/Phlebitis/Thrombophlebitis: Deep vein thrombosis - May-Thurner syndrome - Portal vein thrombosis - Budd-Chiari syndrome - Renal vein thrombosis - Paget-Schroetter disease - Post-thrombotic syndrome Varicose veins: Varicocele - Gastric varices - Portacaval anastomosis (Hemorrhoid, Esophageal varices, Caput medusae) Superior vena cava syndrome - Venous ulcer Arteries or veins Vasculitis - Thrombosis - Embolism (Pulmonary embolism, Cholesterol embolism) Lymphatic vessels/nodes Lymphadenitis - Lymphedema - Lymphangitis Blood pressure Hypertension: Hypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension) Hypotension: Orthostatic hypotension See also congenital (Q20-Q28, 745-747)