Subclavian steal syndrome: Difference between revisions
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==Background== | ==Background== | ||
* A stenosis of the subclavian artery, proximal to the origin of the vertebral vessel, results in decreased perfusion pressure to the distal subclavian artery, leading to retrograde flow in the ipsilateral vertebral artery with exercise of the ipsilateral arm. In short, the arm steals blood flow from the vertebrobasilar system resulting in neurologic and upper extremity symptoms due to arterial insufficiency. <ref> Potter BJ, Pinto DS. Subclavian steal syndrome. ''Circulation.'' 2014; 129(22):2320-3.</ref> | *A stenosis of the subclavian artery, proximal to the origin of the vertebral vessel, results in decreased perfusion pressure to the distal subclavian artery, leading to retrograde flow in the ipsilateral vertebral artery with exercise of the ipsilateral arm. In short, the arm steals blood flow from the vertebrobasilar system resulting in neurologic and upper extremity symptoms due to arterial insufficiency. <ref> Potter BJ, Pinto DS. Subclavian steal syndrome. ''Circulation.'' 2014; 129(22):2320-3.</ref> | ||
* There is an increased incidence of left-sided subclavian stenosis | *There is an increased incidence of left-sided subclavian stenosis | ||
* The presence of collateral blood supply is the main determinant of which patients develop neurologic symptoms | *The presence of collateral blood supply is the main determinant of which patients develop neurologic symptoms | ||
[[File:Subclavian Steal Diagram.png|thumb|Subclavian Steal Diagram]] | [[File:Subclavian Steal Diagram.png|thumb|Subclavian Steal Diagram]] | ||
===Etiology=== | ===Etiology=== | ||
* Atherosclerosis | *Atherosclerosis | ||
* Thoracic Outlet | *Thoracic Outlet | ||
* Congenital Anomalies | *Congenital Anomalies | ||
* Takayasu's Arteritis | *Takayasu's Arteritis | ||
==Clinical Features== | ==Clinical Features== | ||
===Symptoms in Upper Extremity=== | ===Symptoms in Upper Extremity=== | ||
* Pain | *Pain | ||
* Fatigue | *Fatigue | ||
* Coolness | *Coolness | ||
* Paresthesias | *Paresthesias | ||
* Numbness | *Numbness | ||
===Neurologic Symptoms=== | ===Neurologic Symptoms=== | ||
* Dizziness, Lightheadedness | *Dizziness, Lightheadedness | ||
* [[Vertigo]] | *[[Vertigo]] | ||
* [[Syncope]] | *[[Syncope]] | ||
==Differential Diagnosis <ref> De Lorenzo R. Syncope. In: Marx J, ed. ''Rosen's Emergency Medicine.'' 8<sup>th</sup> ed. Philadelphia, PA: Elsevier Saunders; 2014: 135-141. </ref>== | ==Differential Diagnosis <ref> De Lorenzo R. Syncope. In: Marx J, ed. ''Rosen's Emergency Medicine.'' 8<sup>th</sup> ed. Philadelphia, PA: Elsevier Saunders; 2014: 135-141. </ref>== | ||
* Thoracic Outlet Syndrome | *Thoracic Outlet Syndrome | ||
* [[Verebrobasilar Insufficiency]] | *[[Verebrobasilar Insufficiency]] | ||
* [[Syncope]] | *[[Syncope]] | ||
* [[Vertigo]] | *[[Vertigo]] | ||
==Evaluation== | ==Evaluation== | ||
===Physical Exam Findings=== | ===Physical Exam Findings=== | ||
* Supraclavicular bruit, thrill | *Supraclavicular bruit, thrill | ||
* Systolic BP in ipsilateral brachial artery is reduced compared to opposite side | *Systolic BP in ipsilateral brachial artery is reduced compared to opposite side | ||
* Ipsilateral radial pulse with decreased amplitude and delayed arrival | *Ipsilateral radial pulse with decreased amplitude and delayed arrival | ||
===Diagnostic Tests <ref> Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of vertebral-artery blood flow. ''NEJM.'' 1980; 302(24):1349-51</ref>=== | ===Diagnostic Tests <ref> Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of vertebral-artery blood flow. ''NEJM.'' 1980; 302(24):1349-51</ref>=== | ||
* Routine testing for atherosclerosis: Lipid | *Routine testing for atherosclerosis: Lipid panel, Glucose | ||
* Doppler | *Doppler ultrasound | ||
* Chest | *Chest x-ray, EKG | ||
* CTA, MRA | *CTA, MRA | ||
* Angiography | *Angiography | ||
==Management== | ==Management== | ||
===Medical Management=== | |||
===Medical | #Treat atherosclerosis | ||
# Treat atherosclerosis | #Antiplatelet therapy | ||
# Antiplatelet | #Anticoagulant therapy | ||
# Anticoagulant | ===Surgical Management=== | ||
===Surgical | |||
Indicated for symptomatic patients | Indicated for symptomatic patients | ||
# Angioplasty with | #Angioplasty with endovascular stenting | ||
# CEA (in patients with associated carotid disease) by increasing collateral blood flow | #CEA (in patients with associated carotid disease) by increasing collateral blood flow | ||
# Surgical | #Surgical bypass | ||
==Disposition== | ==Disposition== | ||
* If symptomatic, admit with consults to Vascular Surgery, Neurology | *If symptomatic, admit with consults to Vascular Surgery, Neurology | ||
* If incidental finding, consider close outpatient follow up | *If incidental finding, consider close outpatient follow-up | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Neurology]][[Category:Vascular]] | |||
[[Category:Neurology]] | |||
Revision as of 11:53, 19 August 2016
Background
- A stenosis of the subclavian artery, proximal to the origin of the vertebral vessel, results in decreased perfusion pressure to the distal subclavian artery, leading to retrograde flow in the ipsilateral vertebral artery with exercise of the ipsilateral arm. In short, the arm steals blood flow from the vertebrobasilar system resulting in neurologic and upper extremity symptoms due to arterial insufficiency. [1]
- There is an increased incidence of left-sided subclavian stenosis
- The presence of collateral blood supply is the main determinant of which patients develop neurologic symptoms
Etiology
- Atherosclerosis
- Thoracic Outlet
- Congenital Anomalies
- Takayasu's Arteritis
Clinical Features
Symptoms in Upper Extremity
- Pain
- Fatigue
- Coolness
- Paresthesias
- Numbness
Neurologic Symptoms
Differential Diagnosis [2]
- Thoracic Outlet Syndrome
- Verebrobasilar Insufficiency
- Syncope
- Vertigo
Evaluation
Physical Exam Findings
- Supraclavicular bruit, thrill
- Systolic BP in ipsilateral brachial artery is reduced compared to opposite side
- Ipsilateral radial pulse with decreased amplitude and delayed arrival
Diagnostic Tests [3]
- Routine testing for atherosclerosis: Lipid panel, Glucose
- Doppler ultrasound
- Chest x-ray, EKG
- CTA, MRA
- Angiography
Management
Medical Management
- Treat atherosclerosis
- Antiplatelet therapy
- Anticoagulant therapy
Surgical Management
Indicated for symptomatic patients
- Angioplasty with endovascular stenting
- CEA (in patients with associated carotid disease) by increasing collateral blood flow
- Surgical bypass
Disposition
- If symptomatic, admit with consults to Vascular Surgery, Neurology
- If incidental finding, consider close outpatient follow-up
References
- ↑ Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. 2014; 129(22):2320-3.
- ↑ De Lorenzo R. Syncope. In: Marx J, ed. Rosen's Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 135-141.
- ↑ Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of vertebral-artery blood flow. NEJM. 1980; 302(24):1349-51