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Received date: 04/12/2022 Published date: 303/02/2023 Review Article

Subclavian Steal Syndrome

JAYESH TRIVEDI¹*, TWINKLE RANA², HARDIK CHAUDHARY², SHAIL JANI², SAGAR SOLANKI², FARHAN PIPRANI²

¹Head of Department and Professor of Medicine, Gujarat Adani Institute of Medical Science, Bhuj Gujarat, India
²Student, General medicine, Gujarat Adani Institute of Medical Science, Bhuj Gujarat, India

*Corresponding author

*JAYESH TRIVEDI, Head of Department and Professor of Medicine, Gujarat Adani Institute of Medical
Science, Bhuj Gujarat, India

DOI: 10.55920/JCRMHS.2023.03.001110

INTRODUCTION

The subclavian steal syndrome is characterized by subclavian artery stenosis which is proximal to the origin of the vertebral artery. The subclavian artery steals reverse-flow blood from the vertebrobasilar artery circulation to supply the arm on exertion, resulting in vertebrobasilar insufficiency. The vertebrobasilar arterial system supplies both the peripheral and central auditory and vestibular systems, in subclavian steal syndrome, neurological symptoms are expected due to VBI (vertebrobasilar insufficiency).

Coronary variant of subclavian-vertebral artery steal syndrome which occur as adverse effect of coronary artery bypass while using the arm on the same side of the internal mammary artery graft used to bypass the narrowed or obstructed coronary vessel. This variant results in symptoms of cardiac ischemia like angina or can also cause acute myocardial infarction. Symptoms are more marked with the movements of the affected limb

On movement of the upper limb person will have symptoms due to VBI in the form of dizziness, vomiting, vertigo and in acute case can lead to infarct of the medulla also, headache is also one of the feature

Etiology

The most common aetiology of SSS is atherosclerosis. Subclavian steal syndrome is seen more on the left side, Due to the acute origin of the left subclavian artery, that leads to increased turbulence, causing more wear and tear in intima of the arteries resulting in atherosclerosis with or without dyslipidaemia

Some of the other risk factors for Subclavian steal syndrome are:

Takayasu arteritis, which is a large vessel granulomatous vasculitis, commonly seen in young and middle-aged females
It will be a thoracic outlet syndrome presentation. This presentation presents in athletes as cricket bowlers and baseball pitchers, due to neuromuscular compression, here the subclavian artery crosses over the first rib.
Cervical rib, which is an additional rib that comes from the seventh cervical vertebra in the form of long transverse process
Post-operative in coarctation of the aorta
Congenital abnormalities as right aortic arch
Others: aortic dissection, vertebral artery congenital malformations, and external vertebral artery compression
Tuberculous arteritis may also present as subclavian steal syndrome more in left upper limb

Pathophysiology

The Subclavian artery lesions usually are not symptomatic due to the rich collateral blood supply in the head and neck. These lesions cause neurological symptoms when compensatory flow to the subclavian artery from the vertebral artery diverts too much flow toward the arm and away from intra-cranial structures leading to VBI. The most important collateral circulation to the posterior fossa is through the circle of Willis

Blood flow diversion from the brain territories to the arm, cause symptoms of VBI, More during the strenuous exercise of the arm or abrupt sharp turning of the head in the direction of the same side. These symptoms come due to two types of mechanisms by which the arm steals blood flow from the vertebrobasilar territory; a lack of blood supply because of subclavian artery stenosis or a malformation disease, that may include an arteriovenous distal arm shunt.

SYMPTOMS

It is usually asymptomatic in patients. It can be a incidentally finding when there is a blood pressure difference between the arms or on arterial doppler studies of patients with coronary/carotid artery disease.

In diabetics many of times SSS is seen with early changes of atherosclerosis in the carotids, it can be diagnosed by carotid intima media thickness ratio, on-invasive tool

Presentation can be pain on affected arm, fatigue, numbness, or paraesthesia’s. The symptoms are on account of the upper extremity ischemia while doing vigorous exercise particularly in cricketers and basketball players or weight lifters

Neurological symptoms due to vertebrobasilar insufficiency are dizziness, blurring of vision, syncope, vertigo, disequilibrium, ataxia, tinnitus, and hearing loss. They can be unmasked by carrying out vigorous upper limb exercises

Blood pressure alterations in both upper limbs more than 15 mmhg should raise a suspicion of SSS which should be differentitated from supravalvular aortic stenosis particularly in right upper limb

Palpation of radial pulses in both arms shows a decreased volume and late pulse on the affected side.

Screening of bilateral carotid arteries should be regularly done in such cases

DIAGNOSIS

SSS should be sought of in patients with VBI neurological symptoms like arm ischemic pains during exercise or at rest, coronary ischemia where the Internal mammary artery has been used for coronary artery bypass graft surgery. Blood pressure variations of amplitudes of 15 mmhg systolic should raise a suspicion. Bruit in the suboccipital area can be heard. Sometimes atrophic changes can be seen in nails. Finding of diminished pulses at multiple sites suggests Takayasu’s arteritis. It should be differentiated from syringomyelia associated vascular changes

CRP levels will also be high as a marker of endothelial sydfunction due to inflammatory process in the endocardium.

Non-invasive technique like CWD, PWD and colour doppler are accurately used when performed by a good operator. Transcranial Doppler may be more useful in the setting of neurological symptoms. MR angiography and CT angiography can also be used, Best used to find the severity of subclavian artery stenosis. MR angiography is superior to CT angiography for correct diagnosis and the sensitivity and specificity is more than 90%

Small size left subclavian artery which is 1.97 mm as compared to normal subclavian artery width 5-6 mm in one of our cases of a 25 year old female patient who presented with dizziness and vomiting

MANAGEMENT

Subclavian artery stenosis is a marker of atherosclerotic disease in many patients and hence indicates the risk of adverse cardiovascular events in such patients. These patients benefit from secondary preventive measures, including control of blood pressure, treatment of dyslipidemia, smoking cessation, glycemic control in diabetes mellitus, and lifestyle changes.

Invasive treatment like percutaneous balloon angioplasty

There is also secondary prevention with the use of aspirin,ace inhibitors, beta blockers ,statins.

Surgical intervention is overshadowed by non invasice techniques like balloon plasties and stenting

Bemphidonic acid in patients with statin side effects can be also given

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Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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