Ipsilateral Subclavian Artery Research Articles

Subclavian Steal Syndrome Like Appearance Resulting from a Vertebral Artery Origin Stenosis: A Case Report

Partial steal has been regarded as a classic ultrasound appearance of subclavian steal syndrome. We report a case with the vertebral artery origin stenosis and intact subclavian artery, which showed the similar partial steal ultrasound features. The following computerized tomography angiography confirmed the stenosis. Therefore, when an alternating flow in the vertebral artery is detected, the investigation of its origin must be performed besides the ipsilateral subclavian artery.

Major Vascular Neck Injury From a Handgun Cartridge Casing

We present a case from the Johannesburg General Hospital of a zone II low-velocity penetrating neck injury with involvement of the ipsilateral subclavian artery. When the "bullet" was retrieved, it was noted not to be an actual bullet but rather a cartridge casing. We speculate that this injury represents one of several possible misfiring scenarios from a homemade firearm. Injuries from homemade firearms are infrequent in the literature, and only one other similar case of a cartridge casing causing a penetrating injury was found. A brief review of homemade handheld firearms is offered.

Massive Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome is an unusual cause of angina, secondary to decreased or reversed flow in patients with patent "in situ" internal mammary-to-coronary artery graft. The most frequent cause of coronary subclavian steal syndrome is ipsilateral subclavian artery stenosis. We present a 60-year-old man with cerebrovascular and peripheral artery disease and a documented massive coronary subclavian steal syndrome, which impaired cardiopulmonary bypass weaning after multiple coronary artery bypass with double T-mammary artery graft.

Drug-Eluting Stents for the Treatment of Vertebral Artery Origin Stenosis

To present our experience with the use of drug-eluting stents (DES) in patients with symptomatic vertebral artery ostium stenosis (VAOS). Between 2003 and 2008, 28 consecutive patients (17 men; mean age 66 years) with symptomatic extracranial vertebral artery stenosis were treated with a paclitaxel-eluting stent. All patients were prospectively scheduled for serial clinical, duplex, and angiographic follow-up to identify restenosis. After stent implantation, the mean stenosis was reduced from 68% to 9%. There were no periprocedural neurological complications. After a mean follow-up of 16 months (range 5-41), no strokes, worsening of symptoms, or deaths occurred. Angiographic restenosis >50% was seen in 6 (21.4%) patients. Restenosis occurred significantly more often in patients with an ipsilateral subclavian artery stenosis (p = 0.01). Radiography during follow-up angiography revealed stent fracture in 1 patient and stent compression/kinking in 11 (39%) of the patients. Stent compression and recoil, not intimal hyperplasia, were the major contributing factors to restenosis. Compared to the restenosis rate of bare metal stents reported in the literature, DES seems to be superior for the treatment of VAOS. However, stent compression and recoil are relevant problems contributing to restenosis. Further improvement of the materials for the interventional treatment of VAOS seems necessary.

MDCT of an Aberrant Right Subclavian Artery and of Bilateral Vertebral Arteries with Anomalous Origins

WEB This is a Web exclusive article. n normal aortic arch anatomy, the left subclavian artery is the most distal branch and both vertebral arteries arise as the first branch of the ipsilateral subclavian artery. Various anatomic variants of the supraaortic arteries have been reported in the literature. We present the MDCT angiographic findings in an unusual case of an aberrant right subclavian artery and anomalous origins of both vertebral arteries.

Subclavian venipuncture following ipsilateral extrapleural dissection is hazardous

Subclavian artery puncture is an infrequent complication of subclavian vein cannulation. In spite of the limited ability to apply direct pressure to the bleeding vessel, significant hematoma or exsanguinating bleeding rarely occurs. This study was a retrospective chart review of a neonate who underwent extrapleural repair of a tracheo-esophageal fistula and sustained significant blood loss following an accidental ipsilateral subclavian artery puncture. This case highlights the importance of an intact apical pleura in controlling bleeding from the subclavian vessels. Thus, ipsilateral percutaneous subclavian venipuncture should be avoided in patients in whom the apical pleura is not intact.

Contrast-Enhanced MR Angiography of Subclavian Steal Syndrome: Value of the 2D Time-of-Flight “Localizer” Sign

Our objective was to determine if direction of flow within the vertebral artery could be reliably determined by evaluation of flow-sensitive, low-resolution 2D time-of-flight (TOF) localizer images taken before 3D contrast-enhanced MR angiography (3D CEMRA) sequences in patients with unsuspected subclavian steal syndrome. Vertebral artery patency on 3D CEMRA in cases in which the vessel is absent on the TOF localizer in association with ipsilateral subclavian artery stenosis indicates reversal of flow in the vertebral artery and confirms the subclavian steal phenomenon. The combination of anatomic imaging with 3D CEMRA with functional information provided by the low-resolution TOF localizer confirms the diagnosis of subclavian steal without additional imaging.

Fatal subclavian stent infection remote from implantation

We report the unusual case of a 66-year-old alcoholic male who presented with acute arm ischemia 4 months following ipsilateral subclavian artery stenting. The patient had a petechial rash and Janeway lesions in the distribution of the affected subclavian artery. He had been treated for an infected dialysis graft 10 days prior to entry into the hospital. Subsequent angiogram confirmed a patent stent with intraluminal filling defects and occlusion of the brachial artery. Thrombectomy yielded material that was consistent with septic emboli and CT scan of the chest was suggestive of a mycotic aneurysm around the stent. The subclavian stent was removed surgically and the aneurysm was repaired. Unfortunately, the patient had multiple comorbidities and died of complications during recovery. This is the first case of a subclavian stent infection following septicemia remote from implantation.

Bronchial to subclavian shunt in a CF patient. A potential pitfall for embolization

Bronchial artery embolization is a well accepted and widely used technique in the management of massive haemoptysis in cystic fibrosis (CF). It can be a complex procedure requiring a deep knowledge of the bronchial artery anatomy including the possible bronchial anastomoses. We report a case of complex vascular anatomy of the left bronchial artery with multiple anastomoses with the ipsilateral subclavian artery as cause of non-attempted embolization.

Arterial fast bolus flush systems used routinely in neonates and infants cause retrograde embolization of flush solution into the central arterial and cerebral circulation.

To evaluate the risk of retrograde embolization of flush solution in neonates and infants with routinely used electronic syringe pumps and infusion bag pump flush systems. With hospital Ethical Committee approval we studied intubated neonates and infants with a 24-GA radial arterial cannula. Fast flush boluses were delivered from the infusion bag pump flush system by opening the flow regulating device for two seconds at bag pump manometre pressures of 100, 200 and 300 mmHg. In the syringe pump flush system, fast flush bolus volumes of 0.5, 1.0, 1.5 and 2.0 mL were programmed on the electronic syringe pump and released by opening the flow regulating device for two seconds. A 12-MHz ultrasonic probe placed in the jugular fossa was used to detect white bubbles indicating retrograde embolization of flush solution into the ipsilateral subclavian and common carotid artery. Sixteen patients, aged from 1-105 days (median 22 days) were studied. In all patients retrograde embolization into the subclavian artery was detected at syringe pump bolus volumes of 0.5-1.5 mL and at 100-200 mmHg bag pump pressure. In nine of the 16 patients a positive signal was detected in the common carotid artery with 1.5-2.0 mL syringe pump bolus volumes and at 200-300 mmHg bag pump pressure. In neonates and infants, the standard practice of arterial fast bolus flushing using syringe pump and bag pump flush systems causes retrograde embolization of flush solution into the central arterial and even into the cerebral circulation. The mandatory limitation of fast flush bolus volumes and manometre pressures is urgent in order to reduce retrograde embolization of flush solution and the associated risks in these small patients.

Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery

Objective: To identify the incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. Design: Prospective. Setting: Veterans Affairs Medical Center and university-affiliated medical center. Participants: Adult patients with prior coronary artery bypass graft surgery and documented use of an internal mammary artery. Interventions: Bilateral simultaneous brachial blood pressures were determined noninvasively. The presumptive diagnosis of ipsilateral subclavian artery stenosis and coronary-subclavian steal syndrome was made if the systolic blood pressure differential was >20 mmHg. Measurements and Main Results: The presumptive diagnosis of ipsilateral subclavian artery stenosis based on a blood pressure differential was made in 6 of 86 (5%) patients screened. The diagnosis of coronary-subclavian steal syndrome was confirmed at cardiac catheterization by observing retrograde internal mammary artery flow in 3 patients or lack of internal mammary artery flow in 1 patient (3.4%). All 4 patients with angiographic confirmation had either angina or silent ischemia. Three patients had successful carotid subclavian bypass, and 1 patient refused surgery. Two patients had no evidence of myocardial ischemia and underwent their planned procedure without incident. Conclusion: Coronary-subclavian steal syndrome occurs with relative frequency in noncardiac surgery patients with prior coronary artery bypass graft surgery using internal mammary artery conduits. Bilateral blood pressure measurements should be routinely performed during the preoperative evaluation. A pressure differential >20 mmHg should suggest the possibility of coronary-subclavian steal syndrome. Copyright © 2001 by W.B. Saunders Company

Traumatic dissection of the common carotid artery after blunt injury to the neck

BACKGROUND Occlusive lesions of the common carotid artery (CCA) resulting from blunt injury are extremely rare, and their clinicopathologic and therapeutic features have not yet been clarified. OBJECTIVES AND RESULTS Five patients with occlusive lesions of the CCA developed neurologic deficits at 1.5 hours to 10 years after blunt neck injury. Lesions included two complete occlusions, one severe stenosis, and two segmental intimal dissections of the CCA. In the two patients with CCA occlusion, bypass surgery was performed using a Dacron graft between the ipsilateral subclavian artery and the carotid bifurcation. In the remaining three patients, the involved segments were replaced with a Dacron graft. Surgical specimens from the early posttraumatic period revealed intimal tears with mural thrombosis and/or subintimal hematomas and those from the later period showed myointimal hyperplasia or fibrotic organization. CONCLUSION Traumatic occlusive lesions of the CCA tend to evolve from intimal dissections to severe stenoses or occlusion, compromising cerebral circulation. The involved CCA can be diagnosed early by B-mode Doppler sonography and successfully reconstructed using a Dacron graft.

The clinical significance of performing preoperative angiography of the internal thoracic artery in coronary artery bypass surgery.

This study was designed to clarify the clinical significance of and indications for performing preoperative internal thoracic artery (ITA) angiography in patients undergoing coronary artery bypass surgery. A total of 300 possible candidates for coronary artery bypass grafting (CABG) underwent ITA angiography during diagnostic catheterization. Semi-selective angiography of bilateral ITAs were performed by injecting contrast medium manually with a 5-F right Judkins coronary catheter. The posteroanterior view of the arteriograms was recorded on a 35-mm cine film or a cut-film. Unusual angiographic findings of the ITAs were observed in nine patients (3%). These findings included: an atrophic ITA in three patients with ipsilateral subclavian artery occlusions; enlarged ITAs giving collaterals to the lower extremities in one patient with extensive aortoiliac occlusive disease; occluded ITAs in one patient with Takayasu's arteritis and two patients with a history of CABG; and a small but nonsclerotic ITA in one patient. Atherosclerotic occlusive ITAs were found in only one patient. Thus, we concluded that routine preoperative angiography of the ITA is not necessary because it is rarely affected by atherosclerosis. However, it should be performed for any of the following reasons: a cervical or supraclavicular bruit; an upper extremity blood pressure difference of greater than 20 mmHg; an extensive aortoiliac occlusion; and certain disorders such as Takayasu's arteritis or Kawasaki disease, or a history of open heart surgery.

Vertebral Artery Reconstruction: Results in 106 Patients

Between January 1982 and December 1989, we performed 109 revascularizations of the vertebral artery in 106 patients. Eighty-six patients (81%) had isolated vertebrobasilar insufficiency, 18 (17%) had associated carotid and vertebrobasilar pathology while two (2%) had isolated carotid symptoms. The procedures performed included 98 revascularizations of the proximal vertebral artery and 11 reconstructions of the distal vertebral artery. One distal revascularization was required after early failure of proximal revascularization. In 36 cases (34%), a concomitant ipsilateral carotid artery revascularization procedure was performed, and in one case, an ipsilateral subclavian artery aneurysm was excised. Two patients (1.9%) died postoperatively and five patients (4.7%) had nonfatal neurologic complications. Four of these seven complications occurred after combined vertebral and carotid surgery. One hundred early follow-up arteriograms were obtained (92% of reconstructions). There were four occlusions, two of which were associated with neurologic deficits. Three patients were lost to follow-up. Mean follow-up was 48 months (4-100 months). Seven patients died in the late follow-up period (after one month). Actuarial five year survival was 91%. Overall patency at five years was 96%. The study of late neurologic events showed that 63% of patients had complete recovery, 30% improvement, and 7%, failure or aggravation of symptoms.

Extra-intracranial Bypass Procedure with Saphenous Vein Grafts

This study reports on 13 cases of extra-intracranial bypass procedures using saphenous vein grafts. Ten patients had arteriosclerotic occlusive vascular disease, one patient had a giant aneurysm of the internal carotid artery, another 2 females, 18 and 28 years of age, respectively, suffered from Takayasu's disease. Preoperatively all patients had severe neurological symptoms. To keep the venous graft as short as possible, as a first choice the carotid artery, in case of occlusive disease of the latter as a second choice the ipsilateral subclavian artery, or as a third choice the ascending aorta, were used as donor vessels. Perioperatively, one patient sustained an intracerebral/intraventricular hemorrhage and, despite immediate reoperation, died in a vegetative state early postoperatively. Another patient had a minor perioperative cerebral stroke with complete recovery. None of the other patients had any additional neurological deficit perioperatively, and they had complete relief from ischemic attacks postoperatively. There was one early occlusion due to high competitive collateral flow, and one late occlusion due to technical problems. The overall patency rate of surviving patients was 83.3% (follow-up 3 to 23 months).

The Significance of Scapular Fractures

Scapular fractures in the multiply injured patient have received little attention. Fifty-six patients with 58 scapular fractures secondary to blunt trauma were reviewed. The patients averaged 3.9 major injuries excluding their scapular fractures. The injury pattern associated with blunt scapular fracture is unique. Patients with scapular fracture have a high incidence of injury to the ipsilateral lung and chest wall and to the ipsilateral shoulder girdle and its contained structures: rib fractures, 53.6%; pulmonary contusions, 53.6%; clavicular fracture, 26.8%; brachial plexus injury, 12.5%; subclavian, brachial, or axillary artery injury, 10.7%. Eight patients died (14.3%). Although no patient died from the scapular fracture, half of the deaths in this series were the result of pulmonary sepsis arising in an associated ipsilateral pulmonary contusion. Scapular fractures provide the trauma surgeon with a reliable clinical clue that the patient is at inordinate risk to have associated injuries of major consequence to the ipsilateral lung and chest wall, the ipsilateral shoulder girdle, and the ipsilateral subclavian, axillary, or brachial artery.

Vascular origin of Poland syndrome?

Vascularization of the arms has been studied by impedance plethysmography (rheography) in eight children with Poland syndrome, a common malformation characterized by unilateral hand anomaly and ipsilateral aplasia of the inferior head of the pectoralis major muscle. A marked decrease of the velocity of the systolic increase in the arterial volume (Velm) was shown in the affected arms, and the difference between the two arms was significantly higher in the patients than in a control group (P less than 0.02). These results, which are also observed in stenotic atherosclerosis, support the hypothesis of hypoplasia of the ipsilateral subclavian artery as the origin of the malformation, although a local anomaly in arterial-wall viscosity cannot be ruled out. The opacification of the aortic arch in another patient confirmed this hypothesis. Aortography in further patients will be necessary to substantiate our results. However, this technique is not without danger and should only be used during the first months of life when a vascular operation can be envisaged.

EVALUATING INDIRECT BLOOD PRESSURE TECHNIQUES–A COMPARATIVE STUDY

An accurate systolic blood pressure (SBP) can now be measured indirectly in all infants & children with an ultrasonic flow detector (UFD) and an inflatable cuff of appropriate size & design. Two semi-automatic blood pressure devices, Arteriosonde 1010 (A) & Infrasonde (I), are purported to accurately measure both SBP and diastolic blood pressure (DBP). A two-Pronged study was designed to evaluate the accuracy of indirect blood pressure obtained with A, I, & a new plastic (Pedisphyg) cuff (PC). In part one, with the cuff of either A, I, or PC systems applied to the upper arm in random and sequential fashion & with a catheter in the ipsilateral subclavian artery, simultaneous direct & indirect pressures were recorded & compared. In part two, A, I, & PC systolic BP values alone were compared by performing simultaneous measurements on both upper arms of selected infants previously shown to have identical SPP in both arms. Comparisons were made hy random application of A, I, & PC to each arm. In this two-pronged study, 125 comparisons revealed that (1) with a properly sized plastic cuff and an ultrasonic flow detector, systolic BP can be measured accurately but not diastolic BP, (2) A & I frequently fail to sound a distinct signal to mark SBP accurately, & even with a relatively good signal the plastic cuff & UFD system is more accurate than A or I, (3) neither A nor I accurately marks DBF and should not he relied upon for this measurement.