Recurrent Subclavian Steal Syndrome: A Novel Case of Vasculopathy

Abstract

Subclavian steal syndrome (SSS) refers to the phenomenon of retrograde flow in an ipsilateral branch of the subclavian artery due to hemodynamically significant stenosis or occlusion of the ipsilateral proximal subclavian artery. While SSS is usually asymptomatic, it can manifest as vertebrobasilar insufficiency (VBI), ischemia of the affected extremity, or cardiac angina when an internal mammary artery (IMA) is used as a bypass graft. The underlying etiology is most often atherosclerosis but can include Takayasu arteritis, thoracic outlet syndrome, cervical rib, and stenosis secondary to surgical repair of aortic coarctation or tetralogy of Fallot.There are several case reports describing unique presentations of SSS as well as limited reports of double SSS, where the brachiocephalic steno-occlusive disease causes flow reversal in both the ipsilateral vertebral and carotid arteries. We report herein the first documented case, to our knowledge, of a patient with SSS previously treated with left subclavian artery stenting and left common carotid-subclavian bypass who developed recurrent SSS in conjunction with orthostatic cerebral hypoperfusion syndrome (OCHOS) secondary to severe vasculopathy. She presented with recurrent, paroxysmal vertigo and nearsyncope associated with left upper extremity paresthesias that would only abate with sitting in the context of left subclavian artery stent restenosis and occlusion of her left common carotid-subclavian bypass graft. Interestingly, her initial presentation entailed retrograde flow from the left vertebral artery to the left subclavian artery, classic for SSS, but recurrence of her SSS involved retrograde flow from the left common carotid artery to the left subclavian artery, a phenomenon which has also not been described in the literature to our knowledge. As her symptoms of VBI appeared to be triggered by standing and not left arm movement, they were considered to be primarily secondary to OCHOS. Consequently, her primary treatment was to increase salt and fluid intake and thus increase intravascular volume for improved cerebral perfusion as she was not deemed to be a suitable candidate for regrafting of the left subclavian artery.

A Novel Case of Anomalous Origin of Left Vertebral Artery Associated With Left Subclavian Steal Syndrome

“…While most of the patients with the underlying condition remain asymptomatic, they can present with symptoms of VBI (dizziness while moving left arm), upper extremity claudication, or cardiac angina [2]. Symptomatic SSS presentation is more often seen in males over 50 years of age with a 2:1 male-to-female ratio [1,6]. The branching patterns of the aortic arch were studied by Popieluszko et al, in the meta-analysis of 23,882 adult aortic arches from 51 studies which showed that the most common branching pattern (from right to left), brachiocephalic trunk, the LCCA, and the LSCA with an overall incidence of 80.9% [7].…”

“…SSS is a condition associated with the reversal of blood flow in the ipsilateral vertebral artery due to hemodynamically significant stenosis or occlusion of the ipsilateral PSCA [ 1 , 2 ]. The incidence and prevalence of SSS are not very well defined due to asymptomatic presentation [ 6 ]. The studies have shown the incidence of subclavian artery occlusion of 17% and 9% of them were symptomatic [ 6 ].…”

“…The incidence and prevalence of SSS are not very well defined due to asymptomatic presentation [ 6 ]. The studies have shown the incidence of subclavian artery occlusion of 17% and 9% of them were symptomatic [ 6 ]. The atherosclerotic disease remains the most common etiology; however, other conditions to consider include thoracic outlet syndrome, cervical rib, Takayasu arteritis, and stenosis due to surgical repair of coarctation of aorta or tetralogy of Fallot [ 2 ].…”

“…While most of the patients with the underlying condition remain asymptomatic, they can present with symptoms of VBI (dizziness while moving left arm), upper extremity claudication, or cardiac angina [ 2 ]. Symptomatic SSS presentation is more often seen in males over 50 years of age with a 2:1 male-to-female ratio [ 1 , 6 ].…”