Subclavian steal syndrome
- Peter C Spittell, MD
Peter C Spittell, MD
- Assistant Professor of Medicine
- Mayo Medical School
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
The term "subclavian steal" refers to a phenomenon of flow reversal in the vertebral artery ipsilateral to a hemodynamically significant stenosis or occlusion of the prevertebral subclavian artery [1-3]. In most cases, subclavian steal is asymptomatic (ie, subclavian steal phenomenon), does not warrant invasive evaluation or treatment, and represents an appropriate physiological response to proximal arterial disease. Subclavian steal syndrome implies the presence of significant symptoms due to arterial insufficiency in the brain (ie, vertebrobasilar insufficiency) or upper extremity, which are supplied by the subclavian artery (figure 1).
The physiology, diagnosis, and treatment of subclavian steal will be reviewed here. General considerations for patients with symptoms of vertebrobasilar ischemia are discussed in detail elsewhere. (See "Posterior circulation cerebrovascular syndromes".)
DEFINITION AND PHYSIOLOGY
Classic subclavian steal — Subclavian artery occlusion or a hemodynamically significant stenosis proximal to the origin of the vertebral artery results in lower pressure in the distal subclavian artery [4,5]. As a result, blood flows from the contralateral vertebral artery to the basilar artery and may flow in a retrograde direction down the ipsilateral vertebral artery, away from the brainstem (figure 2) [6,7]. Reversed vertebral artery flow, although it may have deleterious neurologic effects, serves as an important collateral artery for the arm in this setting.
Coronary-subclavian steal — A coronary-subclavian steal phenomenon has been described in patients who have undergone prior coronary artery bypass surgery (CABG) using the internal mammary artery (IMA) [8-10]. The prevalence of subclavian artery stenosis is 2.5 to 4.5 percent in patients referred for coronary artery bypass grafting . In the presence of a hemodynamically significant subclavian artery stenosis proximal to the origin of the ipsilateral IMA, flow through the internal mammary artery may reverse and "steal" flow from the coronary circulation during upper extremity exercise (figure 3). Coronary and graft angiography will demonstrate retrograde flow in the involved IMA during selective catheterization of the grafted coronary artery .
Simultaneous coronary and cerebrovascular ischemia have also been reported [10,13]. Identification of a significant subclavian artery stenosis prior to CABG can prevent this important problem. Those patients with a high-grade subclavian artery stenosis should be treated (percutaneously or surgically) prior to CABG . For patients with symptomatic subclavian lesions who require coronary artery bypass, no differences were seen for complications, mortality, or symptom recurrence, using a combined or staged approach to revascularization .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- CONTORNI L. [The vertebro-vertebral collateral circulation in obliteration of the subclavian artery at its origin]. Minerva Chir 1960; 15:268.
- REIVICH M, HOLLING HE, ROBERTS B, TOOLE JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med 1961; 265:878.
- Fisher, CM . A new vascular syndrome: "The subclavian steal. " N Engl J Med 1961; 265:912.
- Ochoa VM, Yeghiazarians Y. Subclavian artery stenosis: a review for the vascular medicine practitioner. Vasc Med 2011; 16:29.
- Toole JF, McGraw CP. The steal syndromes. Annu Rev Med 1975; 26:321.
- PATEL A, TOOLE JF. SUBCLAVIAN STEAL SYNDROME--REVERSAL OF CEPHALIC BLOOD FLOW. Medicine (Baltimore) 1965; 44:289.
- Saha T, Naqvi SY, Ayah OA, et al. Subclavian Artery Disease: Diagnosis and Therapy. Am J Med 2017; 130:409.
- Cua B, Mamdani N, Halpin D, et al. Review of coronary subclavian steal syndrome. J Cardiol 2017; 70:432.
- Ochi M, Yamauchi S, Yajima T, et al. Simultaneous subclavian artery reconstruction in coronary artery bypass grafting. Ann Thorac Surg 1997; 63:1284.
- Takach TJ, Beggs ML, Nykamp VJ, Reul GJ Jr. Concomitant cerebral and coronary subclavian steal. Ann Thorac Surg 1997; 63:853.
- Sintek M, Coverstone E, Singh J. Coronary subclavian steal syndrome. Curr Opin Cardiol 2014; 29:506.
- Nguyen NH, Reeves F, Therasse E, et al. Percutaneous transluminal angioplasty in coronary-internal thoracic-subclavian steal syndrome. Can J Cardiol 1997; 13:285.
- Rogers JH, Calhoun RF 2nd. Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era. J Card Surg 2007; 22:20.
- Hwang HY, Kim JH, Lee W, et al. Left subclavian artery stenosis in coronary artery bypass: prevalence and revascularization strategies. Ann Thorac Surg 2010; 89:1146.
- Hong H, Wu L, Yang C, Dong NG. Results of a hybrid procedure for patients with proximal left subclavian artery stenosis and coronary artery disease. J Thorac Cardiovasc Surg 2016; 152:131.
- Fields WS, Lemak NA. Joint Study of extracranial arterial occlusion. VII. Subclavian steal--a review of 168 cases. JAMA 1972; 222:1139.
- Labropoulos N, Nandivada P, Bekelis K. Prevalence and impact of the subclavian steal syndrome. Ann Surg 2010; 252:166.
- Nicholls SC, Koutlas TC, Strandness DE. Clinical significance of retrograde flow in the vertebral artery. Ann Vasc Surg 1991; 5:331.
- Shadman R, Criqui MH, Bundens WP, et al. Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases. J Am Coll Cardiol 2004; 44:618.
- KESTELOOT H, VANHOUTE O. REVERSED CIRCULATION THROUGH THE VERTEBRAL ARTERY. Acta Cardiol 1963; 18:285.
- Rodriguez-Lopez JA, Werner A, Martinez R, et al. Stenting for atherosclerotic occlusive disease of the subclavian artery. Ann Vasc Surg 1999; 13:254.
- Gutierrez GR, Mahrer P, Aharonian V, et al. Prevalence of subclavian artery stenosis in patients with peripheral vascular disease. Angiology 2001; 52:189.
- Chatterjee S, Nerella N, Chakravarty S, Shani J. Angioplasty alone versus angioplasty and stenting for subclavian artery stenosis--a systematic review and meta-analysis. Am J Ther 2013; 20:520.
- Saalouke MG, Perry LW, Breckbill DL, et al. Cerebrovascular abnormalities in postoperative coarctation of aorta. Four cases demonstrating left subclavian steal on aortography. Am J Cardiol 1978; 42:97.
- Kurlan R, Krall RL, Deweese JA. Vertebrobasilar ischemia after total repair of tetralogy of Fallot: significance of subclavian steal created by Blalock-Taussig anastomosis. Vertebrobasilar ischemia after correction of tetralogy of Fallot. Stroke 1984; 15:359.
- MASSUMI RA. THE CONGENITAL VARIETY OF THE "SUBCLAVIAN STEAL" SYNDROME. Circulation 1963; 28:1149.
- Luetmer PH, Miller GM. Right aortic arch with isolation of the left subclavian artery: case report and review of the literature. Mayo Clin Proc 1990; 65:407.
- Kajinami K, Mori K, Masuda S, et al. Asymptomatic congenital subclavian steal in a young male patient with right aortic arch. Chest 1990; 97:481.
- Savastano S, Feltrin GP, Chiesura-Corona M, Miotta D. Cerebral ischemia due to congenital malformations of brachiocephalic arteries--case reports. Angiology 1992; 43:76.
- Bornstein NM, Krajewski A, Norris JW. Basilar artery blood flow in subclavian steal. Can J Neurol Sci 1988; 15:417.
- Bornstein NM, Norris JW. Subclavian steal: a harmless haemodynamic phenomenon? Lancet 1986; 2:303.
- Lord RS, Adar R, Stein RL. Contribution of the circle of Willis to the subclavian steal syndrome. Circulation 1969; 40:871.
- Salam TA, Lumsden AB, Smith RB 3rd. Subclavian artery revascularization: a decade of experience with extrathoracic bypass procedures. J Surg Res 1994; 56:387.
- Klingelhöfer J, Conrad B, Benecke R, Frank B. Transcranial Doppler ultrasonography of carotid-basilar collateral circulation in subclavian steal. Stroke 1988; 19:1036.
- Mousa AY, Morkous R, Broce M, et al. Validation of subclavian duplex velocity criteria to grade severity of subclavian artery stenosis. J Vasc Surg 2017; 65:1779.
- Harper C, Cardullo PA, Weyman AK, Patterson RB. Transcranial Doppler ultrasonography of the basilar artery in patients with retrograde vertebral artery flow. J Vasc Surg 2008; 48:859.
- Sharma VK, Chuah B, Teoh HL, et al. Chronic brainstem ischemia in subclavian steal syndrome. J Clin Neurosci 2010; 17:1339.
- Dieter RS. The Dieter test. Expert Rev Cardiovasc Ther 2009; 7:221.
- Huang Y, Gao S, Wang B, Li S. The evaluation of intra- and extra-cranial circulation in subclavian steal syndrome. Chin Med J (Engl) 1997; 110:286.
- Kliewer MA, Hertzberg BS, Kim DH, et al. Vertebral artery Doppler waveform changes indicating subclavian steal physiology. AJR Am J Roentgenol 2000; 174:815.
- Van Grimberge F, Dymarkowski S, Budts W, Bogaert J. Role of magnetic resonance in the diagnosis of subclavian steal syndrome. J Magn Reson Imaging 2000; 12:339.
- Nael K, Villablanca JP, Pope WB, et al. Supraaortic arteries: contrast-enhanced MR angiography at 3.0 T--highly accelerated parallel acquisition for improved spatial resolution over an extended field of view. Radiology 2007; 242:600.
- Tsao TF, Cheng KL, Shen CY, et al. Diagnostic Performance of Combined Contrast-Enhanced Magnetic Resonance Angiography and Phase-Contrast Magnetic Resonance Imaging in Suspected Subclavian Steal Syndrome. Can Assoc Radiol J 2016; 67:190.
- Sheehy N, MacNally S, Smith CS, et al. Contrast-enhanced MR angiography of subclavian steal syndrome: value of the 2D time-of-flight "localizer" sign. AJR Am J Roentgenol 2005; 185:1069.
- Park KH, Lee HY, Lim C, et al. Clinical impact of computerised tomographic angiography performed for preoperative evaluation before coronary artery bypass grafting. Eur J Cardiothorac Surg 2010; 37:1346.
- Aboyans V, Criqui MH, McDermott MM, et al. The vital prognosis of subclavian stenosis. J Am Coll Cardiol 2007; 49:1540.
- Vitti MJ, Thompson BW, Read RC, et al. Carotid-subclavian bypass: a twenty-two-year experience. J Vasc Surg 1994; 20:411.
- Walker PM, Paley D, Harris KA, et al. What determines the symptoms associated with subclavian artery occlusive disease? J Vasc Surg 1985; 2:154.
- Chang JB, Stein TA, Liu JP, Dunn ME. Long-term results with axillo-axillary bypass grafts for symptomatic subclavian artery insufficiency. J Vasc Surg 1997; 25:173.
- Smith JM, Koury HI, Hafner CD, Welling RE. Subclavian steal syndrome. A review of 59 consecutive cases. J Cardiovasc Surg (Torino) 1994; 35:11.
- De Vries JP, Jager LC, Van den Berg JC, et al. Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results. J Vasc Surg 2005; 41:19.
- Iared W, Mourão JE, Puchnick A, et al. Angioplasty versus stenting for subclavian artery stenosis. Cochrane Database Syst Rev 2014; :CD008461.
- Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999; 33:1238.
- Wang KQ, Wang ZG, Yang BZ, et al. Long-term results of endovascular therapy for proximal subclavian arterial obstructive lesions. Chin Med J (Engl) 2010; 123:45.
- Che WQ, Dong H, Jiang XJ, et al. Stenting for left subclavian artery stenosis in patients scheduled for left internal mammary artery-coronary artery bypass grafting. Catheter Cardiovasc Interv 2016; 87 Suppl 1:579.
- Patel SN, White CJ, Collins TJ, et al. Catheter-based treatment of the subclavian and innominate arteries. Catheter Cardiovasc Interv 2008; 71:963.
- Sixt S, Rastan A, Schwarzwälder U, et al. Results after balloon angioplasty or stenting of atherosclerotic subclavian artery obstruction. Catheter Cardiovasc Interv 2009; 73:395.
- Mahmud E, Cavendish JJ, Salami A. Current treatment of peripheral arterial disease: role of percutaneous interventional therapies. J Am Coll Cardiol 2007; 50:473.
- Ahmed AT, Mohammed K, Chehab M, et al. Comparing Percutaneous Transluminal Angioplasty and Stent Placement for Treatment of Subclavian Arterial Occlusive Disease: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2016; 39:652.
- Filippo F, Francesco M, Francesco R, et al. Percutaneous angioplasty and stenting of left subclavian artery lesions for the treatment of patients with concomitant vertebral and coronary subclavian steal syndrome. Cardiovasc Intervent Radiol 2006; 29:348.
- DEFINITION AND PHYSIOLOGY
- Classic subclavian steal
- Coronary-subclavian steal
- EPIDEMIOLOGY AND RISK FACTORS
- Risk factors
- CLINICAL FEATURES
- Clinical presentations
- - Asymptomatic
- - Symptomatic
- Upper extremity ischemia
- Neurologic symptoms
- Physical examination
- Noninvasive vascular imaging
- - Duplex ultrasound
- - Transcranial Doppler
- - Magnetic resonance angiography
- - CT angiography
- Differential diagnosis
- Risk modification
- Open surgical bypass
- Endovascular intervention
- SUMMARY AND RECOMMENDATIONS