Subclavian steal syndrome: Difference between revisions

No edit summary
No edit summary
 
(12 intermediate revisions by 4 users not shown)
Line 1: Line 1:
==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>
*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
*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 obstruction]]
* Thoracic Outlet
*Congenital anomalies
* Congenital Anomalies
*[[Takayasu 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]]
===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
==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]]
*[[Vertebrobasilar insufficiency]]
*[[Syncope]]
*[[Vertigo]]


==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>==
{{Shoulder DDX}}
* Thoracic Outlet Syndrome
* [[Verebrobasilar Insufficiency]]
* [[Syncope]]
* [[Vertigo]]


==Evaluation==
==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 <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 Panel, Glucose
*Routine testing for atherosclerosis: Lipid panel, Glucose
* Doppler Ultrasound
*Doppler [[ultrasound]]
* Chest XRay, EKG
*[[CXR]], [[ECG]]
* CTA, MRA
*CTA, MRA
* Angiography
*Angiography


==Management==
==Management==
===Medical Management===
#Treat atherosclerosis
#[[Antiplatelet]] therapy
#[[Anticoagulant]] therapy


===Medical management===
===Surgical Management===
# Treat atherosclerosis
# Antiplatelet Therapy
# Anticoagulant Therapy
 
===Surgical management===
Indicated for symptomatic patients
Indicated for symptomatic patients
# Angioplasty with Endovascular Stenting
#Angioplasty with endovascular stenting
# CEA (in patients with associated carotid disease) by increasing collateral blood flow
#CEA (in patients with associated [[carotid stenosis]]) by increasing collateral blood flow
# Surgical Bypass
#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]]

Latest revision as of 16:19, 3 October 2019

Background

  • 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]
  • Increased incidence of left-sided subclavian stenosis
  • The presence of collateral blood supply is the main determinant of which patients develop neurologic symptoms
Subclavian Steal Diagram

Etiology

Clinical Features

Symptoms in Upper Extremity

Neurologic Symptoms

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

Differential Diagnosis [2]

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

Diagnostic Tests [3]

  • Routine testing for atherosclerosis: Lipid panel, Glucose
  • Doppler ultrasound
  • CXR, ECG
  • CTA, MRA
  • Angiography

Management

Medical Management

  1. Treat atherosclerosis
  2. Antiplatelet therapy
  3. Anticoagulant therapy

Surgical Management

Indicated for symptomatic patients

  1. Angioplasty with endovascular stenting
  2. CEA (in patients with associated carotid stenosis) by increasing collateral blood flow
  3. Surgical bypass

Disposition

  • If symptomatic, admit with consults to Vascular Surgery, Neurology
  • If incidental finding, consider close outpatient follow-up

References

  1. ↑ Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. 2014; 129(22):2320-3.
  2. ↑ De Lorenzo R. Syncope. In: Marx J, ed. Rosen's Emergency Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014: 135-141.
  3. ↑ Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of vertebral-artery blood flow. NEJM. 1980; 302(24):1349-51
Retrieved from "https://www.wikem.org/w/index.php?title=Subclavian_steal_syndrome&oldid=231820"