SUBCLAVIAN STEAL Preceptor : dr. Yuwono, Sp.

S, FINS
Clinical Clerkship Neurology
Rotation

SYNDROME Royal Taruma Hospital

Period of 26 November – 30
December 2018
OUTLINE
Definition

Pathophysiology

Clinical manifestation

Diagnosis

Management

Summary
 “SUBCLAVIAN STEAL SYNDROME”
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 JMed. 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
 PATHOPHYSIOLOGY

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

 CLINICAL
MANIFESTATION

brain heart

Upper
extremity

Reivich M, Holling HE, Roberts B, Toole JF.Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl JMed. 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
 CLINICAL
MANIFESTATION
Brain (vertebrobasilar insufficiency)
• Drop attacks
• Dizziness
• Diplopia
• Nystagmus
• Hearing loss
• Tinnitus
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 JMed. 1961;265:878–885.
 CLINICAL
MANIFESTATION

Upper extremity
• Arm claudication
• Exercise-induced pain and fatigue
• 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 JMed. 1961;265:878–885.
 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
 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
Kurien M, Bottomley JR, McGrath EE.Takayasu arteritis. Eur JCardiothorac Surg. 2011;40:1268.
Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular medicine practitioner. Vasc Med. 2011;16:29–34.
Rogers JH, Calhoun RF2nd. Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era. JCard 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 JMed. 2011;124:e1–e2.
 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.

 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 SCJr, 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 JMed. 2013;126:693–700.e691
 MANAGEMENT

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