Extrathoracic Surgical Treatment of Subclavian Steal Syndrome

Extrathoracic Surgical Treatment of Subclavian Steal Syndrome

Mohamed Salem,1 Amr Salem,1 Sherif Salem2

1Department of Vascular Surgery, Medical Research Institute, Alexandria University, Egypt

2Department of Neurosurgery, Faculty of Medicine, Alexandria University, Egypt

Twelve patients with” subclavian steal syndrome” were studied in 36 months period from June 2013 to June

2016. Their age ranged between 21-55 years with a mean age of 32 years. Female sex represented (7/12,

58.33%). All cases were subjected to complete history taking and clinical examination. They presented with drowsiness and, or fainting after left upper limb exercise. This was associated with manifestations of chronic left upper limb ischemia. Investigations were done for all cases including laboratory investigations, Duplex US, Angiography and CT Angiography. Surgical treatment was done for all cases (7 cases were treated by transcervical subclavian -subclavian bypass graft, 4 cases were treated by left common carotid to left subclavian artery bypass graft and one case by right subclavian to left axillary artery bypass graft). Ringed Gortex graft 8mm was used in all cases. The results of all surgical operations were successful and the symptoms of the brain and left upper limb ischemia disappeared. The graft in one case was occluded after 2½ years due to intimal hyperplasia (the case of right subclavian to left axillary artery bypass graft). Clearance of the graft was done by using Fogarty catheter. All grafts were functioning well and the results were excellent.

Key Words: Left upper limb ischemia, fainting, coma, subclavian steal syndrome,subclavian artery stenosis.

Introduction

“Subclavian steal” means  reversal of flow in a branch of the subclavian artery that is due to an ipsilateral  hemodynamically  significant lesion  of the proximal subclavian artery.1,2

Subclavian stenoses however, are most often asymptomatic and therefore do not require specific therapy other than that directed at the underlying etiology. In some patients with “Subclavian steal syndrome” symptoms of arterial insufficiency affecting the brain and the upper extremity become manifested.1-3

Atherosclerosis is the most common cause of “subclavian steal syndrome” irrespective of the clinical manifestation, however, large artery vasculitis, thoracic outlet syndrome, and stenosis after surgical treatment of aortic coarctation are other possible causes.2-4

The phenomenon of reversed flow in the vertebral artery  in  the  setting  of  proximal  subclavian artery stenosis5  is relatively rare and usually asymptomatic6    due  to  adequate  compensation by the circle of Willis and a rich brachiocephalic collateral  circulation.  However,  symptoms  can arise when these pathways are compromised by occlusive disease or anatomical variants7,8  leading to  vertebrobasilar  or  upper  extremity  ischemia or  even  myocardial  ischemia  from  diminished flow through an internal mammary artery bypass graft.7,9,10  In these circumstances, surgical or endovascular intervention is indicated.

Over  the  past  decades,  endovascular  therapy

(angioplasty and stenting) and a variety of extrathoracic surgical approaches [carotid- subclavian bypass (CSB), axilloaxillary bypass (AAB), and subclavian-to-carotid transposition] have been advocated to treat subclavian lesions and avoid transthoracic approaches because of their greater morbidity and mortality.11-14

Aim of the work

This work aimed to evaluate the results of extra thoracic surgical treatment of “subclavian steal syndrome”.

Patients and methods

Patients

This study included 12 patients with “subclavian steal syndrome” attending “the Vascular Unit, Department of Surgery, Faculty of Medicine, Alexandria University, Egypt”. In the period from June 2013 to June 2016.

Inclusion criteria:

1.   Brain ischemia.

2.   Left upper limb ischemia

Exclusion criteria:

1.   Intracranial tumor.

2.   Intracranial thrombosis.

3.   Left upper limb thrombosis.

4.   Left upper limb ulceration or gangrene.

Methods:

After local ethical committee of “the Faculty of Medicine, Alexandria University” approval and obtaining fully informed patients’ consent, the current study was conducted on all patients who

were subjected to the following:

1.   Complete history taking

2.   Thorough clinical examination

3.   Investigations which included:

•    Laboratory investigations

•    Duplex ultrasound

•    Angiography:

− Arch aortography

− CT Angiography

4.   Surgical   treatment   of   12   patients   with

“Subclavian steal syndrome”:

All  extra  thoracic  surgical  bypass  procedures were performed with 8 mm-diameter polytetrafluoroethylene (PTFE) grafts under general anaethesia.

•    Subclavian- Subclavian bypass (SSB)

•    Caratid- Subclavian bypass (CSB)

•    Right  Subclavian-  left  axillary  bypass

(SAB)

5.   Follow up for 12 patients with ”subclavian steal syndrome” through 3 years.

All operations were successful and symptoms disappeared except the case of right subclavian- left axillary graft which was occluded after 2½ years. This graft was revised and cleared using Fogarty catheter. All the 12 grafts were still functioning for 3 years of follow up.

Results

•    Twelve patients presented to the Vasclar Unit with” subclavian steal syndrome” in the period from June 2013 to June 2016.

•    Their ages ranged between 21-55 years with a

mean of 32 years.

•    Female sex represented 7/12, (58.33%).

Table 1: Clinical presentations of 12 patients with”

subclavian steal syndrome”

Fig 1A: Arch aortography showed occlusion of the left subclavian artery, ostial stenosis and attenuated left common carotid artery.

Fig 1B: Ringed Gortex graft between both sub- clavian arteries.

Table 2: Surgical treatment of 12 patients with “subclavian steal syndrome “. All cases were treated by indirect extrathoracic approaches as follows:

Type of operations                                     NO        %

Subclavian – subclavian bypass graft               7       58.33

Fig 1C: Post operative scar of both supraclavicular incisions.

Left common carotid – subclavian bypass

graft

Right subclavian – left axillary bypass

graft

4        33.33

1         8.33

Fig I (A, b,C): Subclavian – subclavian bypass graft.

Fig 2A: Arch aortography showed dilated brachio- cephalic artery and its two branches; the right common carotid and right subclavian artery. Narrowing of the left common carotid artery, occlusion of the left subclavian artery and the axillary artery was reconstituted at its distal half.

Fig 2 B1: Left upper limb ischaemia

(Atrophy and pallor of the left upper limb).

Fig  2  B2:  Three  intra  operative  incisions  and ringed Goretex graft passed through them from the  right  subclavian  artery  to  the  left  distal axillary artery.

Fig 2 B3: Goretex graft was started in the right subclavian artery and was passed transcervical to the left subclavian artery then was passed behind the left clavicle to the left axilla and was anastomosed end to side to the axillary artery.

Fig 2 B4: Showed the scars of the three incisions.

The pallor of the left upper limb was improved

(1 week after operation).

Fig 2C: Postoperative arch aortography showed functioning graft from the right subclavian artery to the left axillary artery.

Fig II (A, B1-4, C): Right subclavian – left axillary artery bypass graft.

As regards the complications postoperatively; there were no brachial plexus injuries, no minor wound complications or graft infection. However, only one patient developed occluded right subclavian to left axillary artery graft after two and half years from operation and was revised using Fogarty catheter to clear the graft.

Postoperatively, the success rate and the graft patency was 100%, the patency was confirmed by Doppler ultrasound. After an average of 3 years follow up, there was no mortality.

Discussion

Patients with subclavian steal are relatively rare and usually asymptomatic6  because of the rich collateral compensation.15,16  Thus, it is generally a benign hemodynamic phenomenon.17-20  However, clinical ischemic symptoms develop when the collateral circulation to the upper extremity is unable to compensate for a decrease in blood supply as a result of anatomical variation or occlusive  disease  in  the  carotid,  vertebral,  or circle of Willis arteries.7,8  In these circumstances, surgical or endovascular treatment of subclavian artery lesion is indicated.

Carotid-subclavian bypass, axilloaxillary bypass and subclavian–subclavian bypass (SSB) were the most common extrathoracic surgical techniques used to treat subclavian steal, and all have excellent long-term outcomes.21-24  However, in patients with concomitant carotid lesions, graft failure is more

frequent in the CSB group. Usually perform CSB in patients without concomitant ipsilateral carotid diseases and AAB in patients with concomitant carotid artery diseases, especially ipsilateral,25

The  age,  sex,  causes  and  symptoms  of  the

”subclavian steal syndrome” in our study were matched with those mentioned in the literature, as Osiro et al17 mentioned that the vertebrobasilar symptoms include paroxysmal vertigo, dizziness, diplopia, ataxia, dysarthria and syncopal attacks. Ischemia to the hand often manifests as arm weakness, claudication, paresthesias or coldness in the arm.

The complication postoperatively was temporary mild numbness in three fingers of the left hand in one patient operated on with right subclavian to left axillary bypass and disappeared after two weeks. Later on, this patient developed occlusion in the right subclavian to left axillary bypass graft after two and half years from the time of the operation. The lumen of the graft was cleared by Fogarty catheter.

No  infection  occurred  in  any  graft  and  no motor dysfunction occurred. All the grafts were still functioning up till now and all symptoms disappeared.

Carotid–subclavian bypass surgery has been used successfully in patients who have isolated steno- occlusive subclavian disease. Patency rates have been reported as high as 95% at 10 years.21,22,26

The widely cited retrospective study by AbuRahma and colleagues22  of the results of 51 carotid- subclavian bypass surgeries showed no mortality after almost 8 years of follow-up, with symptoms recurring in only four of the patients. Also, Qi et al.27  have reported a series of operations with a success rate of up to 98.11% (52 out of 53 cases). Only one complication of thrombogenesis occurred at an anastomotic site, after an average of 24.5 months  of  follow-up.  There  was  no  mortality and the postoperative graft patency rate, con- firmed by Doppler ultrasound, was 100%. All the vertebrobasilar and arm ischemic symptoms had also disappeared. This revascularization technique is therefore still regarded as a low-risk procedure for symptomatic patients whose donor carotid arteries lack significant atherosclerotic disease.

In the present study, the success rate was 100%. After an average of 36 months follow up, there was no mortality and the postoperative graft patency rate was confirmed by Doppler ultrasound. Those  results  were  matched  with  the  results of the previous studies done by AbuRahma and colleagues,22 Uurto et al26 and Qi et al.27

Today, many authers select subclavian artery stenting first for “subclavian steal syndrome”. When endovascular therapy is unsuccessful initially or fails due to in-stent stenosis/ occlusion during follow-up, surgical revascularization with a CSB or AAB or SSB using a PTFE graft can provide an effective and durable treatment option.

Conclusions

Our results showed that extra thoracic surgical bypass using PTFE grafts are safe, easily done and effective for treating “subclavian steal syndrome”.

Extrathoracic surgical bypasses are more durable

in the long term.

References

1.   Potter BJ, Pinto DS: Subclavian steal syndrome.

Circulation 2014; 129: 2320-2323.

2.   Ochoa VM, Yeghiazarians Y: Subclavian artery stenosis: A review for the vascular medicine practitioner. Vasc Med 2011; 16: 29–34.

3.   Aboyans V, Kamineni A, Allison MA, Mc Dermott MM, Crouse JR, Ni H, et al: The epidemiology of subclavian stenosis and its association with markers of subclinical atherosclerosis: The Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2010; 211: 266–270.

4. Labropoulos N, Nandivada P, Bekelis K: Prevalence and impact of the subclavian steal syndrome. Ann Surg 2010; 252:166–170.

5.   Fisher CM: New vascular syndrome, “subclavian steal”. N Engl J Med 1961; 265: 912-913.

6.   Walker PM, Paley D, Harris KA, Thompson A, Johnston KW: What determines the symptoms associated with subclavian artery occlusive disease? J Vasc Surg 1985; 2:154-157.

7.   Hennerici M, Klemm C, Rautenberg W: The subclavian steal phenomenon: A common vascular disorder with rare neurologic deficits. Neurology 1988; 38: 669-673.

8.  Moran KT, Zide RS, Person AV, Jewell ER: Natural history of subclavian steal syndrome. Am Surg 1988; 54: 643-644.

9.   Taylor   CL,   Selman   WR,   Ratcheson   RA: Steal affecting the central nervous system. Neurosurgery 2002; 50: 679-688.

10. Stagg SJ 3rd, Abben RP, Chaisson GA, Kowalski JM, Ladd WR, Meldahl RV, et al: Management of the coronary-suclavian steal syndrome with balloon angioplasty. A case report and review

of the literature. Angiology 1994; 45: 725-731.

11. Farina  C,  Mingoli  A,  Schultz  RD,  Castrucci M, Feldhaus RJ, Rossi P, et al: Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease. Am J Surg

1989; 158: 511-514.

12. Ballotta E, Da Diau G, Abbruzzese E, Mion E, Manara R, Baracchini C: Subclavian carotid transposition for symptomatic subclavian artery  stenosis  or  occlusion: A  comparison with the endovascular procedure. Int Angiol

2002; 21:138-144.

13. Modari B, Ali T, Dourado R, Reidy JF, Taylor PR, Burnand KG: Comparison of extra- anatomic  bypass  grafting  with  angioplasty for atherosclerotic disease of the supra-aortic trunks. Br J Surg 2004; 91:1453-1457.

14. AbuRahma AF, Bates MC, Stone PA, Dyer B, Armistead L, Scott Dean L, et al: Angioplasty and stenting versus carotid-subclavian bypass for the treatment of isolated subclavian artery disease. J Endovasc Ther 2007; 14: 698-704.

15. Newton  TH,  Wylie EJ: Collateral circulation associated with occlusion of the proximal subclavian and innominate arteries. Am J Roentgenol Radium Ther Nucl Med 1964; 91:

394-405.

16. Maggard F: Haemodynamic studies in occlusive disease of the subclavian artery and the brachiocephalic trunk in man. Scand J Thorac Cardio Vasc Surg 1974; 17: 3-59.

17. Osiro S, Zurada A, Gleleckl J, Shoja M, Tubbs S, Loukas M: A review of suclavian steal syndrome with clinical correlation. Med Sci Monit 2012; 18: RA57-RA63.

18. Ackermann H, Diener HC, Dichgans J: Stenosis and occlusion of the subclavian artery: Ultra- sonographic  and  clinical  findings.  J  Neurol

1987; 234:396-400.

19. Fields   WS,   Lemak   NA:   Joint   study   of extracranial arterial occlusion. Vll. Subclavian steal - a review of 168 cases. JAMA  1972;

222:1139-1143.

20. Ueda K, Toole JF, McHenry LC: Carotid and vertebrobasilar transient ischemic attacks: Clinical and angiographic correlation. Neurology

1979; 29:1094-1101.

21. Vitti  MJ,  Thompson  BW,  Read  RC,  Gagne

PJ, Barone GW, Barnes RW, et al: Carotid-