Subclavian Steal Syndrome

1. Subclavian Steal Syndrome
Ade Wijaya, MD – November 2017

2. Outline
 Definition
 Pathophysiology
 Clinical manifestation
 Diagnosis
 Management
 Summary

3. “Subclavian steal”
refers to a phenomenon of flow reversal in a branch of the subclavian artery that is the
result of an ipsilateral hemodynamically significant lesion of the proximal subclavian
artery
Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med. 1961;265:878–885. 2.
Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular medicine practitioner. Vasc Med. 2011;16:29–34

4. Pathophysiology
Potter, B. J., & Pinto, D. S. (2014). Subclavian steal syndrome.Circulation, 129(22), 2320-2323.

5. Clinical Manifestation
brain
Upper
extremity
heart
Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med. 1961;265:878–885.
Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular medicine practitioner. Vasc Med. 2011;16:29–34.
Hennerici M, Klemm C, Rautenberg W. The subclavian steal phenomenon: a common vascular disorder with rare neurologic deficits. Neurology. 1988;38:669–673.
Schatzl S, Karnik R, Gattermeier M. Coronary subclavian steal syndrome: an extracoronary cause of acute coronary syndrome. Wien Klin Wochenschr. 2013;125:437–438

6. Clinical Manifestation
Brain (vertebrobasilar insufficiency)
 Drop attacks
 Dizziness
 Diplopia
 Nystagmus
 Hearing loss
 Tinnitus
Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med. 1961;265:878–885.
Hennerici M, Klemm C, Rautenberg W. The subclavian steal phenomenon: a common vascular disorder with rare neurologic deficits. Neurology. 1988;38:669–673.

7. Clinical Manifestation
Upper extremity
 Arm claudication
 Exercise-induced pain and fatique
 Coolness and paresthesia
Hennerici M, Klemm C, Rautenberg W. The subclavian steal phenomenon: a common vascular disorder with rare neurologic deficits. Neurology. 1988;38:669–673.
Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med. 1961;265:878–885.

8. Clinical Manifestation
Heart
 In patients who have undergone CABG using internal mammary arteries
 Ipsilateral upper extremity exercise may lead to stolen phenomenon
  angina or even infarction
Schatzl S, Karnik R, Gattermeier M. Coronary subclavian steal syndrome: an extracoronary cause of acute coronary syndrome. Wien Klin Wochenschr. 2013;125:437–438

9. Diagnosis
(physical examination)
 A discrepancy of >15 mmHg in blood pressure readings taken in both upper
extremities
 Pulsus paradoxus or pulsus deficit
 Bruit in supraclavicular fossa
 Suboccipital bruit
 Ipsilateral atrophic skin and nails
Rogers JH, Calhoun RF 2nd. Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era. J Card Surg. 2007;22:20–25.
Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. Lancet.
2012;379:905–914.
Betensky BP, Jaeger JR, Woo EY. Unequal blood pressures: a manifestation of subclavian steal. Am J Med. 2011;124:e1–e2.
Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular medicine practitioner. Vasc Med. 2011;16:29–34.
Kurien M, Bottomley JR, McGrath EE. Takayasu arteritis. Eur J Cardiothorac Surg. 2011;40:1268.

10. Diagnosis
 Continuous wave Doppler and duplex ultrasonography
 Transcranial Doppler
 CT/MR angiography
Potter, B. J., & Pinto, D. S. (2014). Subclavian steal syndrome.Circulation, 129(22), 2320-2323.

11. Management
 Asymptomatic or mild symptomatic patients
 Increased cardiovascular risk
 Should be treated by medical treatment:
Aspirin,
β-blockade,
Angiotensin converting enzyme inhibition,
Statin
Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC Jr, Hoffman E, Goto S, Ohman EM, Bhatt DL; REduction of Atherothrombosis for Continued Health Registry Investigators. Adherence to
secondary prevention medications and four-year outcomes in outpatients with atherosclerosis. Am J Med. 2013;126:693–700.e691

12. Management
(symptomatic)
 Balloon angioplasty and stenting
 Surgery
Potter, B. J., & Pinto, D. S. (2014). Subclavian steal syndrome.Circulation, 129(22), 2320-2323.

13. Summary
 SSS is a reversal arterial flow due to proximal subclavian artery stenosis
 Mostly asymptomatic
 Symptoms my include brain, heart, and upper extremity symptoms
 Diagnosis through history and physical examination and supported by ultrasound
or angiography
 Treatment options including medications, stenting, and surgery

14. THANK YOU