Brachiocephalic Artery Disease Progression Resulting in Complex Steal Phenomena

Abstract

Severe brachiocephalic artery stenoses are relatively rare obstructions of the extracranial arteries and can cause significant changes to hemodynamics and spectral Doppler waveform patterns, complicating diagnosis. This case study presents disease progression from stenosis to occlusion and resulting complex steal phenomena extending to the contralateral upper extremity, which has not been widely reported. The sonographic findings of disease progression and collateral pathways were confirmed by magnetic resonance angiography and contrast-enhanced computed tomography.

Inversão total do fluxo em artéria carótida interna direita em paciente com estenose grave do tronco braquiocefálico

“…1,14,17 The most often reported finding (in 13 articles) was partial reversal of flow in the internal carotid artery, with retrograde flow during systole, but antegrade flow in diastole. 2,3,[5][6][7][8][9][10]16,18,20,21,24 Just two studies described complete reversal of flow in the internal carotid throughout the entire cardiac cycle: Grant et al 11 observed reversal with minimal diastolic flow and Borne et al 4 observed reverse flow throughout the whole cardiac cycle, but with systolic velocity of 37 cm/s. In our review, we did not find any cases of such high-velocity reversal as in the case described here, with systolic velocities approaching 100 cm/s (Figure 3).…”

“…The likelihood of pseudo-occlusion is possibly higher in the BCT than in the internal carotid artery, taking into account the vessel's deep location. 3 With regard to treatment, it is well-known that the BCT is a complex region to approach, because of its large diameter, short length, and anatomy including bifurcation to the subclavian and common carotid arteries. 25 Another point that merits attention is transfemoral access, which may not be possible because of poor conditions along the route (femoral and iliac arteries and the aorta).…”

“…Ackerstaff et al 17 1984 Only mentions the common carotid Borne et al 4 2015 Total reversal Brunhölzl and von Reutern 12 1989 Hypoflow without reversal Calin et al 18 2018 Partial reversal Deurdulian et al 2 2016 Partial reversal Esen et al 5 2016 Partial reversal Filis et al 6 2008 Partial reversal Grant et al 11 2006 Total reversal Grosveld et al 14 1988 Only mentions the common carotid Guedes et al 1 2016 Only mentions the common carotid Han et al 7 2017 Partial reversal Horrow et al 19 2008 Hypoflow without reversal Maier et al 20 2014 Partial reversal Racy 10 2019 Partial reversal Rawal et al 13 2019 Hypoflow without reversal Rodriguez 3 2016 Partial reversal Schwend et al 21 1995 Partial reversal Scoutt 15 2019 Hypoflow without reversal Sidhu e Morarji 22 1995 Hypoflow without reversal Tenny and Fleischmann 9 2017 Partial reversal Verlato et al 23 1993 Hypoflow without reversal Uzun et al 8 2008 Partial reversal Willoughby et al 16 2014 Partial reversal Zwiebel and Pellerito 24 2005 Partial reversal…”

“…Stenoses or occlusions of the brachiocephalic trunk (BCT, innominate artery) are rare and can present with a variety of clinical signs. [1][2][3] Since the right subclavian artery and the right common carotid artery originate from the BCT, there may be manifestations of right upper limb ischemia, vertebrobasilar ischemia due to subclavian steal, or hemispheric symptoms related to carotid flow. 2,4 Supplementary findings seen on vascular Doppler ultrasonography (USD) are highly variable.…”

Significant Stenosis of the Brachiocephalic Trunk and Moderate Stenosis of the Left Circumflex Artery in Computed Tomography Angiography Images

“…Most often, the steal syndrome affects the left subclavian artery and results from the narrowing of its proximal part [ 2 ]. In the articles published so far there are few case reports of the brachiocephalic steal syndrome [ 3 , 4 , 5 , 6 ]. In summary, they note that, in contrast to the subclavian steal, brachiocephalic trunk stenosis induces distinct and much more significant hemodynamic alterations in extracranial arterial flow and is rarely asymptomatic.…”