CAR 11. Rare Supra-aortic Steal Syndromes—Endovascular Approach

Abstract

Supra-aortic vessel occlusive disease can rarely be manifested as steal syndrome. Innominate steal syndrome is the reversal of flow in the right carotid artery due to stenosis or occlusion of the innominate artery. Coronary-subclavian steal syndrome (CSSS) can occur in patients with internal mammary artery (IMA)-coronary artery bypass graft because of significant ipsilateral subclavian artery stenosis resulting in reversed blood flow from the myocardium to the upper limb. We report two cases of innominate steal syndrome and CSSS and present a literature review. Case 1: A 64-year-old man was admitted with dizziness, nausea, paresthesia, and claudication in the right arm of 48 hours’ evolution. Head computed tomography excluded acute ischemic lesions. Color duplex ultrasound examination revealed severe stenosis of the innominate artery (peak systolic velocity of 384 cm/s), occlusion of the right vertebral artery, and total flow inversion of the right internal carotid artery. Computed tomography angiography confirmed a preocclusive stenosis of the innominate artery. Puncture of the right brachial artery and exposure of the right common carotid artery were performed. Brain protection was achieved by direct clamping of the common carotid artery. A kissing stent technique was performed with balloon-expandable stents. Direct expulsion of eventual embolic material was performed before declamping. The postoperative period was uneventful without recurrence of symptoms. Case 2: A 61-year-old woman was submitted to coronary artery bypass grafting of the left IMA to the left anterior descending artery and a venous graft to the marginal artery 9 years earlier. The patient remained asymptomatic until 3 months earlier, when she developed chest pain on exertion, particularly when using the left arm. Computed tomography angiography revealed a critical stenosis at the proximal left subclavian artery, without apparent lesions on the venous graft or IMA graft. Under local anesthesia, primary stenting of the lesion was performed. Control angiography showed a fast flow without residual stenosis of the left subclavian artery and good visualization of the IMA graft and left vertebral artery. At 6-month follow-up, the patient remained asymptomatic and without restenosis on color duplex ultrasound. Although rare, supra-aortic vessel steal syndromes can lead to disabling strokes and to life-threatening conditions, especially CSSS. These case reports highlight the importance of color duplex ultrasound in diagnosis and the feasibility of the endovascular approach.