Steal Syndrome Research Articles

Coronary artery steal syndrome in patient after coronary arteries by-pass surgery and left subclavian artery stenting-is the maintenance of a patent internal mammary artery still necessary?

Coronary artery steal syndrome in patient after coronary arteries by-pass surgery and left subclavian artery stenting-is the maintenance of a patent internal mammary artery still necessary?

‘Bovine Ark’ Anomalisi ve Subklavyan Çalma Sendromu Olan Hastanın Başarılı Endovasküler Tedavisi

‘Bovine Ark’ Anomalisi ve Subklavyan Çalma Sendromu Olan Hastanın Başarılı Endovasküler Tedavisi

A rare case of persistent hypoglossal artery associated with contralateral proximal subclavian stenosis.

The persistent hypoglossal artery is rare vascular anomalies. We report the case of a 50-year old man with right hypoglossal artery, ipsilateral hypoplasic internal carotid artery, associated with left proximal subclavian stenosis with subclavian steal syndrome. Power-Doppler-Ultra-Sonography spectral images obtained after the patient exercised the left arm showed mid-systolic deceleration with retrograde late-systolic velocities. A Computed Tomography Angiography demonstrated a proximal stenosis of the left SA, a mild right ICA hypoplasia and an anomalous artery arising from right ICA at C2–C3 level, entering the cranium via the hypoglossal canal and joining the basilar artery. Usually the presence of PHA may be completely asymptomatic, and detected as an incidental finding by CTA or MRA, but in our case its diagnosis is extremely important because it is often the only vessel supplying blood to the basilar trunk and posterior circulation.

An Update on Doppler Ultrasound of Vertebral Arteries: Subclavian Steal Syndrome

A sindrome do roubo da subclavia refere-se a uma desordem vascular na qual ocorre inversao do fluxo de sangue da arteria vertebral ipsilateral, decorrente de uma estenose proximal a sua origem, geralmente uma oclusao da arteria subclavia ou, mais raramente, do tronco braquiocefalico. E uma doenca relativamente rara, relatada em aproximadamente 6% dos pacientes assintomaticos com sopros cervicais. O Doppler pulsado (PW) e util na analise da arteria vertebral, registrando informacoes capazes de identificar a presenca da Sindrome do Roubo da Subclavia. Com base nas alteracoes hemodinâmicas da arteria vertebral avaliadas pelo estudo com Doppler espectral, pode ser classificada nos tipos 1 (oculto), 2 (intermitente ou parcial) e 3 (completo). Com o advento da angioplastia transluminal percutânea e, em seguida, dos stents, muitos advogam essa combinacao de procedimentos como o tratamento de escolha dos casos sintomatico dessa sindrome.

Thrombosis of an Arteria Lusoria with Secondary Subclavian Steal Syndrome and Swallowing Difficulties.

We report a case of an arteria lusoria causing swallowing difficulties known as dysphagia lusoria. Although the presence of an arteria lusoria is quite common, dysphagia lusoria is relatively rare. Interestingly, our patient also presented with a concurrent aneurysmal dilatation, known as a Kommerell’s diverticulum, at the aortic origin. Complete thrombosis of the artery and flow reversal in the right cervical artery resulting in an asymptomatic subclavian steal syndrome was also seen. No underlying primary pro-thrombotic defects were identified but due to the presence of locally advanced prostate cancer, a paraneoplastic phenomenon was suspected.

Comparing Percutaneous Transluminal Angioplasty and Stent Placement for Treatment of Subclavian Arterial Occlusive Disease: A Systematic Review and Meta-Analysis

Subclavian artery occlusive disease (SAOD) is often associated with cerebrovascular symptoms such as subclavian steal syndrome and stroke. We conducted a systematic review and meta-analysis to compare percutaneous transluminal angioplasty (PTA) and stent placement for the treatment of SAOD. We searched Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through October 16, 2014. From each study, we abstracted baseline patient characteristics, study design variables, and outcome data including rates of technical success, primary patency (≤2 and >2 years follow-up), symptom resolution, and complications. Meta-analysis was performed using a random-effects model. A total of 35 non-comparative studies with 1726 patients were included. Technical success rate was significantly higher in the stent group than the PTA group (92.8 vs 86.8%, p = 0.007). Long-term primary patency rates (76.9 vs 79.6%, p = 0.729) and symptom resolution rates (82.2 vs 73.0%, p = 0.327) were not statistically different. There was no statistically significant difference in the rates of stroke or death. Stent placement for treatment of SAOD may be associated with higher rates of technical success but similar rates of symptom resolution and long-term outcomes. The confidence in the available estimates is low. Further comparative studies are needed to guide patients and clinicians in shared decision making.

Three Case Reports of Splenic Artery Steal Syndrome After Liver Transplantation

Splenic artery steal syndrome (SASS) has gained attention as a complication involving the hepatic artery and can cause ischemia in a grafted liver. This article presents 3 patients with SASS, including their diagnosis and treatment. Contrast-enhanced ultrasonography and angiography are useful in diagnosing SASS, and splenic artery trunk embolization is an effective treatment. The purpose of this article is to reinforce the understanding of the development and progression of SASS.

Abstract 14875: Impact of Calcification and Long-Term Outcomes of Intravascular Ultrasound-Guided Stent Implantation for Atherosclerotic Subclavian Artery Obstructive Lesions

Background: Currently, stent implantation for Subclavian artery obstructive lesions (SAOD) is an established method. Intravascular ultrasound (IVUS) provides valuable information for vessel and lumen at pre and post stenting, but there are a few reports on the effect of calcification and long-term outcomes of these methods using IVUS. Methods: We performed IVUS-guided stent implantations for SAOD in 14 arteries of 14 patients between February 2010 and December 2014. The main indications for subclavian artery stenting were arm claudication (10 patients), subclavian steal syndrome (3 patients) and coronary steal syndrome (1 pateint). Ten lesions were stenotic and four lesions were completely obstructed. We divided our patients into 2 groups according to the grade of calcification using IVUS: mild-calc group who showed none or 1/3 circumference calcification in the lesion and severe-calc group who showed more than 1/3 circumference calcification. We compared the IVUS parameters including pre minimum lumen diameter (MLD) (short axis), pre minimum lumen area (MLA), post minimum stent area (MSA), post minimum stent diameter (MSD) (short axis) and symmetric index (minimum/maximum stent diameter) between the two groups. Resutls: IVUS-guided stent implantations for SAOD were successful without perioperative complications in all patients. During follow-up observation (4-60 months, mean 21.8 months), 1 restenosis occurred. Post MSD (short axis) and post MSA were significantly lower in severe-calc group than mild-calc group while there were no significant differences between the two groups. Conclusion: IVUS-guided stent implantation for SAOD achieved satisfactory long-term outcomes. However, calcification may be correlated with worse outcomes in these lesions.

Early cannulation grafts for haemodialysis: a systematic review.

Arteriovenous grafts have advantages compared with central venous catheters for dialysis access and guidelines suggest their use as second choice after arteriovenous fistulas. Standard practice with expanded polytetrafluoroethylene (ePTFE) grafts has been to avoid cannulation for 2 weeks following placement, but new generation grafts have been marketed for their early cannulation properties allowing use as an alternative to central venous catheters for prompt access. The aim of this review is to search the current literature for evidence of early cannulation of new generation grafts and to assess their patency and complication rates. Electronic databases were searched for studies assessing the use of early cannulation grafts for dialysis in accordance with PRISMA. The primary outcomes for this study were primary patency rate, primary-assisted patency rate and secondary patency rate. Secondary outcomes were timing of first cannulation, rates of access thrombosis, steal syndrome, pseudo-aneurysm and infection. Following strict inclusion/exclusion criteria by two reviewers, 15 studies were included in our review and divided into the different types of graft. Flixene, Avflo, Rapidax and Acuseal grafts showed that early cannulation within 72 h was possible; there was no evidence of the use of Vectra within 2 weeks of placement. All grafts showed similar patency and complication rates as previously published data on standard ePTFE grafts. Our review showed that early cannulation is possible without detriment, but data did not allow specific graft recommendations. Therefore, we feel that a multicentre, randomised controlled trial is necessary to compare early cannulation grafts.

The risk factors of splenic arterial steal syndrome after orthotopic liver transplantation

To discuss the risk factors of splenic arterial steal syndrome (SASS) after orthotopic liver transplantation. Twenty-four cases who confirmed SASS after liver transplantation in Tianjin First Central Hospital between June 2005 and June 2013 were analyzed retrospectively. Another 96 cases were selected randomly from those patients of the same time with no complication of SASS patients postoperatively as control group. Clinical data of two groups including diameter of splenic artery and hepatic artery preoperatively, weight of graft, weight of recipients, cold/warm ischemia time, an hepatic period and operation time and so on were collected. Others including hepatic artery peak systolic velocity (PSV), end diastolic velocity (EDV), blood flow resistance index and portal vein average velocity (PVF) on the first day after liver transplantation, the day before diagnosis, the day when diagnosed, the 1, 3, 7 days after treatment in SASS group and on 1, 3, 7, 9, 11, 14 days after liver transplantation in control group. Statistical analysis were made between two groups. The splenic artery/hepatic artery ratio preoperatively and weight of donor liver,and the GRWR in SASS group and control group were 1.26 and 1.00, 1 032 g and 1 075 g, (1.40±0.30)% and (1.82±0.21)% respectively, with significantly statistical differences (Z=-6.40, Z=-2.22, t=-6.50; all P<0.05). The warm ischemia time, the cold ischemia time, the anhepatic period and operation time in SASS group and control group were 3.5 minutes and 4.0 minutes, 10.25 hours and 10.10 hours, 43 minutes and 45 minutes, 8.7 hours and 8.7 hours, with no significantly statistical differences (all P>0.05). RI of hepatic went up gradually in the early time after transplantation while dropped obviously when spleen artery spring coils embolization was received (P<0.01) and trended to stable two weeks later. Splenic artery/hepatic artery ratio and GRWR are the positive and negative risk factors respectively for SASS. The gradual rising of hepatic RI in the early time after transplantation may be the warning signal SASS and spleen artery spring coils embolization is the effective strategy for SASS after liver transplantation.

Steal Syndrome in a Patient with Heart and Kidney Transplantation Caused by Arterio-Venous Fistula

Steal syndrome is an infrequent complication of arteriovenous fistulas (AV) graft for patients on hemodialysis. We report a case of a patient with history of orthotopic heart transplant with end-stage renal disease that subsequently underwent real transplant from a living donor that developed delayed graft function due to steal syndrome of a thigh AV fistula. We discuss the presentation, diagnosis and treatment.

Revision using distal inflow is a safe and effective treatment for ischemic steal syndrome and pathologic high flow after access creation

Ischemic steal syndrome (ISS) and pathologic high flow (HF) are a complications after hemodialysis access creation. Their management is complex and varied with most requiring surgical revision for correction of symptoms. Revision using distal inflow (RUDI) has been described in small series for the treatment of ISS. We present our experience with RUDI for the treatment of ISS and pathologic HF. We retrospectively reviewed consecutive patients who underwent RUDI for ISS from April, 2010 to March, 2014. Data collection included demographic characteristics, medical histories, subsequent procedures, volume flows, access usage, limb salvage, and patient survival. We performed 29 RUDI procedures in 28 patients (16 women, 12 men). Indications for surgery were pathologic HF in 13 and ISS in 19. Ten percent had previous banding for ISS or HF. Sixty-nine percent of patients had a history of diabetes. Fifty-two percent had a history of atherosclerotic disease. Mean time to intervention from creation was 40 months (range, 6-88 months). Accesses included 1 upper arm graft and 27 brachial artery-based fistulas. Outflow included 25 cephalic veins and 3 basilic veins. Distalization targets were 19 radial arteries and 10 ulnar arteries. Mean flow reduction was 1191 mL/min. Primary assisted patency at 1 year was 74%. Secondary patency at 1 year was 87%. A single access was ligated for continued heart failure after RUDI. ISS symptom resolution was reported as complete in 69% and partial in 31%. RUDI is an effective and durable treatment of ISS and HF comparable with reported experiences with distal revascularization-interval ligation, proximalization of the arterial inflow, and banding. Patient selection is key for optimizing relief of symptoms and maintaining use of the access.

The MILLER banding procedure as a treatment alternative for dialysis access steal syndrome: a single institutional experience

ObjectiveTo describe a single institutional experience with minimally invasive limited ligation endoluminal-assisted revision (MILLER) for treatment of dialysis access steal syndrome (DASS). Materials and MethodsTwenty patients were retrospectively identified that underwent 30 MILLER band procedures for DASS at our institution from March 2010 to December 2014. Technical success was defined by successful creation of MILLER band with preservation of flow for hemodialysis. Clinical success was defined as complete resolution of signs and symptoms with preservation of dialysis access in a 1-month postprocedural period. Primary MILLER band patency, postintervention-assisted primary access patency, and postprocedure secondary access patency are reported. ResultsTechnical success was achieved in all patients. Clinical success was achieved in 75% of patients after one banding procedure and in 95% of patients after two banding procedures. One patient experienced access thrombosis following the initial banding procedure which was subsequently treated and did not lead to loss of access. MILLER band patency was 83% at 1 month and 77% at 6 months. Postintervention-assisted primary patency was 95%, 93%, and 92% at 3 months, 6 months, and 1 year, respectively. Postintervention secondary patency was 86%, 68%, and 59% at 3 months, 6 months, and 1 year, respectively. ConclusionsMILLER banding offers a less-invasive alternative to surgical therapy that appears to be safe and permits preservation of dialysis access.

Splenic Artery Steal Syndrome Post Liver Transplant Causing Ischemic Biliary Stricture

Introduction: Splenic artery steal syndrome post liver transplant is rare. If present, there can be significant graft dysfunction and potential graft loss. We present a case of a patient with decompensated cirrhosis secondary to Wilson's disease who underwent orthotopic liver transplant complicated by splenic artery steal syndrome. Case: A 47 yo male was diagnosed with Wilson's disease as a teenager. Thirty years later, he presented with ascites, upper GI bleed, MELD of 40, and transferred to our Transplant Center. He underwent orthotopic liver transplant from a 49 yo healthy O +, Hbcab Igm + donor. Cold ischemic time was 8 hours and 50 minutes and warm ischemic time was 55 minutes. He was given HbIg intraoperatively, started on empiric Entecavir, and given additional HbIg during the first week post-transplant. Liver function tests (LFT's) were noted to be elevated with an ALT 365, AST 576, Total Bilirubin (TB) 21, and INR 2.46 on POD#3. Abdominal doppler showed diminished hepatic arterial flow with a resistive index (RI) of 1.0. Coil embolization of the gastroduodenal artery was done on POD#3 to help improve hepatic perfusion. Post embolization, he was noted to have continued bilirubin elevation (TB 18-20) through POD#6. Repeat abdominal ultrasound showed decreased diastolic flow in the main hepatic artery (RI of 0.79). Diagnostic ERCP showed an anastomotic biliary stricture treated with biliary stenting. His bilirubin trended downward from 18 to 14. Hepatic artery angiogram then showed a large diameter splenic artery with diversion of blood away from the liver. Splenic artery coil embolization was done on POD#9. His LFT's continued to trend downward thereaft er: ALT 132, AST 80, TB 6, INR 1.02. Repeat ERCP at 6 weeks showed an improved anastomotic stricture. Abdominal ultrasound 7 weeks post initial transplant showed adequate hepatic arterial flow (RI of 0.59) with normalization of LFT's. Discussion: Within the first week post-transplant, survival of the liver graft is dependent on adequate arterial oxygen supply. This patient showed signs of splenic arterial steal syndrome, manifested by his elevated liver enzymes. Arterial hypoperfusion of the graft as a result of shift in blood flow into the splenic or gastroduodenal arteries causes hepatic hypoperfusion and potential allograft dysfunction. Timely diagnosis and management with ERCP and IR embolization helped prevent postoperative morbidity and graft loss.

Steal syndrome following an arteriovenous fistula – case report and treatment option

The paper presents the case of a 48 year-old diabetic patient that underwent hemodialysis for a long period of time and presented to our hospital with digital hypoperfusion symptoms following an arteriovenous fistula between the humeral artery and the basilic vein. The anamnesis of the patient reveals prior circulatory problems and in the case of a previous fistula the patient required the amputation of the distal phalanx of the left index finger. The arterial theft syndrome was dealt with in this case by using a simple method based on techniques of flow diminution through the vein, assessing the calibration by means of clinical criteria such as capillary flow, presence of thrill and decrease in pain levels. A 1 year follow-up showed the fistula was still viable and the symptoms diminished to a level that no longer interfered with the lifestyle of the patient.

Approach to the Swollen Arm With Chronic Dialysis Access: It's Not Just Deep Vein Thrombosis.

The purposes of this pictorial essay are as follows: (1) Review a systematic approach to using sonography in the initial evaluation of patients with acute arm swelling and permanent dialysis access. (2) Identify normal grayscale and Doppler findings in arteriovenous fistulas and grafts. (3) Discuss a spectrum of vascular differential diagnoses for arm swelling in this setting, including stenosis of the access, draining vein complications, thrombosis, steal syndrome, and aneurysms, as well as several nonvascular causes. (4) Recognize findings that warrant further imaging evaluation or intervention.

Subclavian steal syndrome decreases neurogenesis in the cerebellar cortex and affects cognitive function in rabbits.

Subclavian steal syndrome (SSS) is a condition characterized by a steno-occlusive impairment of the proximal subclavian artery. The majority of patients with SSS are asymptomatic, while symptomatic patients present with neurological symptoms. SSS is a risk factor for cerebral ischemia, which reacts badly upon cognitive function; however, it remains unknown whether SSS is able to cause progressive cognitive impairment. In the present study, the potential effects of SSS on cognitive function were investigated using atherosclerotic rabbits as a model of SSS. A total of 48 male New Zealand rabbits were divided into the control, sham and SSS groups. The results of eyeblink experiments indicated no significant differences among the three groups; however, SSS did appear to exert a negative impact on neurogenesis in the cerebellar cortex. In order to further clarify the mechanisms underlying this SSS-mediated reduction in cell proliferation, the energy metabolism, immune function and oxidative stress statuses were evaluated by determining the levels of adenosine triphosphate (ATP), adenosine, interleukin (IL)-1β, IL-6, malondialdehyde, 8-hydroxy-2'-deoxyguanosine, CuZn-superoxide dismutase and catalase. The results showed that the levels of extracellular ATP in the cerebellar cortex had decreased, while levels of adenosine had also decreased. These findings suggest that SSS is able to inhibit neurogenesis in the cerebellar cortex by decreasing the extracellular ATP levels. Furthermore, these changes may result in an impairment of the cognition of the rabbits. The early diagnosis and treatment of SSS may, therefore, prevent or mitigate cognitive impairment in the future.

Distal radial artery ligation for treatment of steal syndrome in a distal radiocephalic arteriovenous fistula

Distal radial artery ligation for treatment of steal syndrome in a distal radiocephalic arteriovenous fistula

Distal Radial Artery Embolization: An Alternative Approach to Access Preservation and Limb Salvage in Radiocephalic Arteriovenous Fistulae Complicated by Steal Syndrome

Distal Radial Artery Embolization: An Alternative Approach to Access Preservation and Limb Salvage in Radiocephalic Arteriovenous Fistulae Complicated by Steal Syndrome

A Review of the Endovascular Management of Thoracic Aortic Pathology

Thoracic endovascular aortic repair (TEVAR) has recently gained popularity, but there is ongoing debate surrounding its safety and efficacy. We present 13 years of TEVAR experience at our institution. Data from procedures performed between September 2000 and October 2013 were sourced. Eighty-one TEVARs were performed in 72 patients for various disorders of the thoracic aorta. The mean duration of follow-up was 62 months (range, 2-140 months). One-month, one-year, and five-year survival rates were 93%, 88%, and 63%, respectively. Five mortalities occurred within 30 days of operation (7%), three of which were related to vascular complications. There were 12 episodes of postoperative endoleak (12.5%). The left subclavian artery was covered without revascularisation in nine cases resulting in two episodes of subclavian steal syndrome and one episode of left arm claudication. Three patients had perioperative strokes, and one patient spinal cord ischaemia. We demonstrated low rates of reintervention after TEVAR and a low risk of complications, particularly neurological. We therefore advocate an endovascular approach for thoracic pathology involving the aortic arch and descending aorta, particularly in elderly patients. Coverage of the LSCA is often necessary, but where possible, prophylactic revascularisation should be performed.