RESUMEN
We reported a case of carotid artery stenosis with stroke symptoms detected in a patient with lung cancer after radiotherapy. The patient was a 58-year-old male with a complaint of \"a single episode of temporary amaurosis in the right eye for 10 minutes". The clinical diagnosis at admission, after consideration of the patient's age, medical history, and auxiliary examination results, was as follows: lung cancer; right common carotid artery stenosis; left common carotid artery stenosis; left vertebral artery stenosis; and right subclavian artery occlusion with right subclavian steal syndrome (Grade 3). Carotid angioplasty and stenting (CAS) were subsequently performed. During the 6-month follow-up, we observed no episode of temporary vision loss or other signs of stroke. Clinicians should pay great attention to delayed radiation-induced carotid stenosis. It is recommended that patients with a history of radiotherapy should undergo regular color Doppler ultrasound examination of the cervical region to diagnose, prevent, and treat RICS in an expedient fashion. This approach should improve survival rate and quality of life.
Asunto(s)
Estenosis Carotídea/etiología , Neoplasias Pulmonares/radioterapia , Radioterapia/efectos adversos , Síndrome del Robo de la Subclavia/etiología , Arteria Carótida Común/patología , Arteria Carótida Común/efectos de la radiación , Arteria Carótida Común/cirugía , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/patología , Estenosis Carotídea/cirugía , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/etiología , Traumatismos por Radiación/patología , Traumatismos por Radiación/cirugía , Stents , Arteria Subclavia/patología , Arteria Subclavia/efectos de la radiación , Arteria Subclavia/cirugía , Síndrome del Robo de la Subclavia/diagnóstico , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/cirugía , Ultrasonografía Doppler en Color , Arteria Vertebral/patología , Arteria Vertebral/efectos de la radiación , Arteria Vertebral/cirugíaRESUMEN
A 26-year-old woman with Takayasu's arteritis (TAK) experienced back and neck pain during tocilizumab (TCZ) treatment. The levels of C-reactive protein were normal, and ultrasonography revealed no significant changes. Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS) showed signal enhancement in the walls of several arteries. Contrast computed tomography showed arterial inflammation in the same lesion. After increasing the dose of prednisolone and TCZ, all signal enhancements decreased and continued to decrease, as observed on days 76 and 132. Thus, DWIBS may be a novel imaging modality for assessing the disease activity of TAK, particularly during follow-up.
Asunto(s)
Antiinflamatorios/administración & dosificación , Anticuerpos Monoclonales Humanizados/administración & dosificación , Prednisolona/administración & dosificación , Arteritis de Takayasu/patología , Adulto , Dolor de Espalda/etiología , Proteína C-Reactiva/metabolismo , Arteria Carótida Común , Estenosis Carotídea/etiología , Estenosis Carotídea/patología , Angiografía por Tomografía Computarizada , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Infusiones Intravenosas , Imagen por Resonancia Magnética/métodos , Imagen Multimodal , Dolor de Cuello/etiología , Recurrencia , Síndrome del Robo de la Subclavia/etiología , Síndrome del Robo de la Subclavia/patología , Arteritis de Takayasu/tratamiento farmacológico , Ultrasonografía , Imagen de Cuerpo Entero/métodosRESUMEN
PURPOSE: The study sought to evaluate the efficacy of magnetic resonance imaging (MRI) in patients with suspected subclavian steal syndrome (SSS) using both contrast-enhanced (CE) MR angiography and phase-contrast (PC) MRI. METHODS: Fifteen suspected SSSs from 13 patients were evaluated using CE-MR angiography and PC-MRI. Ten patients also received dynamic CE-MR angiography. RESULTS: All MRI examinations were technically successful. By combining CE-MR angiography with PC-MRI, 10 SSSs were diagnosed in 9 patients. The delay enhancement dynamic technique predicted SSS with a sensitivity, specificity, and accuracy of 57.1%, 100%, and 72.7%, respectively. Without the dynamic technique, affected delay-enhanced arteries were poorly visualized and could be mistaken for occluded vessels. Retrograde vertebral flow by PC-MRI was used to predict ipsilateral SSS with a sensitivity, specificity, and accuracy of 100%, 60%, and 86.7%, respectively. There were 2 false positives including 1 patient with a proximal total occlusion of the affected vertebral artery and another with brachiocephalic steal syndrome rather than SSS. This suggested that retrograde vertebral flow does not always indicate SSS. CONCLUSIONS: CE-MR angiography combined with PC-MRI is efficacious when evaluating SSS in clinical practice.
Asunto(s)
Medios de Contraste , Aumento de la Imagen/métodos , Imagen por Resonancia Magnética/métodos , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Angiografía por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sensibilidad y Especificidad , Síndrome del Robo de la Subclavia/patología , Adulto JovenRESUMEN
Subclavian 'steal' phenomenon is a function of the proximal subclavian artery (SA) steno-occlusive disease, with subsequent retrograde blood flow in the ipsilateral vertebral artery (VA). The symptoms from the compromised vertebrobasilar and brachial blood flows constitute the subclavian steal syndrome (SSS), and include paroxysmal vertigo, drop attacks and/or arm claudication. Once thought to be rare, the emergence of new imaging techniques has drastically improved its diagnosis and prevalence. The syndrome, however, remains characteristically asymptomatic and solely poses no serious danger to the brain. Recent studies have shown a linear correlation between increasing arm blood pressure difference with the occurrence of symptoms. Atherosclerosis of the SA remains the most common cause. Doppler ultrasound is a useful screening tool, but the diagnosis must be confirmed by CT or MR angiography. Conservative treatment is the initial best therapy for this syndrome, with surgery reserved for refractory symptomatic cases. Percutaneous angioplasty and stenting, rather than bypass grafts of the subclavian artery, is the widely favored surgical approach. Nevertheless, large, prospective, randomized, controlled trials are needed to compare the long-term patency rates between the endovascular and open surgical techniques.
Asunto(s)
Síndrome del Robo de la Subclavia/patología , Humanos , Prevalencia , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/fisiopatología , Ultrasonografía DopplerAsunto(s)
Aneurisma Falso/etiología , Angioplastia/efectos adversos , Falla de Prótesis , Stents/efectos adversos , Síndrome del Robo de la Subclavia/terapia , Aneurisma Falso/diagnóstico por imagen , Angiografía , Mano/irrigación sanguínea , Humanos , Masculino , Persona de Mediana Edad , Arteria Subclavia/patología , Síndrome del Robo de la Subclavia/diagnóstico por imagen , Síndrome del Robo de la Subclavia/patología , Tomografía Computarizada por Rayos XRESUMEN
So carotid-subclavian transposition and stenting are effective and safe methods of correction of occlusive subclavian artery disease. Angioplasty and stenting of the subclavian artery is particularly indicated in patients with high surgical risk. Patients at low risk of surgery is preferred execution carotid-subclavian transposition.
Asunto(s)
Angioplastia , Stents , Síndrome del Robo de la Subclavia/terapia , Anciano , Arterias Carótidas/patología , Arterias Carótidas/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Arteria Subclavia/patología , Arteria Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/fisiopatologíaAsunto(s)
Técnicas de Imagen Cardíaca/métodos , Imagen por Resonancia Magnética/métodos , Miocarditis/patología , Síndrome del Robo de la Subclavia/patología , Arteritis de Takayasu/patología , Gadolinio , Humanos , Miocarditis/etiología , Síndrome del Robo de la Subclavia/etiología , Arteritis de Takayasu/complicacionesRESUMEN
Unlike carotid bifurcation atherosclerotic stenosis, supra-aortic trunks (SAT) occlusive disease is rare and its revascularization uncommon, accouting for less than 10% of the operations performed on the extracranial brain-irrigating arteries. There are three different treatment approaches: transthoracic, extra-anatomic cervical and endovascular. Endovascular repair is gaining popularity as first-line therapy for proximal lesions with favorable anatomy because of its low morbidity and rare mortality. Extra-anatomic bypass is a safe and durable reconstruction and should be considered in patients with single vessel disease, with cardiopulmonary high-risk or with limited life expectancy. If cardiac surgery is needed, central transthoracic reconstruction is preferable, and the two procedures should be combined. The long-term patency of bypasses with aortic origin, specially when multiple vessels are involved, is superior to other repair techniques. We present three clinical cases that illustrate each of these therapeutic strategies: central brachiocephalic revascularization and synchronous cardiac surgery in a patient with complex SAT atherosclerosis disease; subclavian-carotid transposition for disabling upper limb claudication; and subclavian artery stenting for subclavian-steal syndrome. Surgical approach selection should be based on the individual patient's anatomy and operative risk.
Asunto(s)
Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Adulto , Anciano , Enfermedades de la Aorta/patología , Arteriopatías Oclusivas/patología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Humanos , Masculino , Persona de Mediana Edad , Selección de Paciente , Procedimientos de Cirugía Plástica/efectos adversos , Procedimientos de Cirugía Plástica/métodos , Stents , Arteria Subclavia/cirugía , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/cirugía , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversosAsunto(s)
Puente de Arteria Coronaria/efectos adversos , Síndrome del Robo de la Subclavia/diagnóstico , Anciano , Angina de Pecho/etiología , Velocidad del Flujo Sanguíneo , Enfermedad Coronaria/cirugía , Humanos , Masculino , Arterias Mamarias/patología , Revascularización Miocárdica , Vena Safena/cirugía , Síndrome del Robo de la Subclavia/patología , Instrumentos Quirúrgicos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular therapy is a treatment option for localized occlusion of the subclavian artery. In this report the long-term experience with 59 patients is presented. METHODS: Between June 1998 and September 2008, we used endovascular therapy to treat 61 subclavian arterial obstructive lesions in 59 patients (46 males and 13 females, 34 - 82 years of age with a mean age (61.9 + or - 11.0) years). Twenty patients (34%) had clinical symptoms due to vertebrobasilar insufficiency, 26 (44%) had disabling arm ischemia, and 13 (22%) had both symptoms. We performed all procedures under local anesthesia. The approaches were from the femoral artery (n = 47), brachial artery (n = 1, involving bilateral subclavian disease) or both (n = 11). Sixty stents were implanted. All patients were followed-up at 1, 3, 6, and 12 months post-procedure, and annually thereafter. RESULTS: We achieved technical success in 58 (95.1%) arteries, all of which were stented. There were three technical failures; two were due to the inability to cross over an occlusion, necessitating the switch to an axillo-axillary bypass, and the third was due to shock after digital subtraction angiography and prior to stenting. Arterial stenosis pre- and post-stenting was (83.6 + or - 10.8)% and (2.5 + or - 12.5)% (P < 0.01). Clinical success was achieved in 55 of the 59 patients (93.4%). Of the four clinical failures, three were technical and the remaining patient had a stent thrombosis. Systolic blood pressure difference between the two brachial arteries was (44.7 + or - 18.5) vs. (2.2 + or - 3.9) mmHg (P < 0.01). Primary patency was 98% at 12 months, 93% at 24 months, and 82% at 5 years. Five patients were lost to follow-up by 12 months post-stenting. Significant recurrent obstruction developed in five patients with resumption of clinical symptoms. The overall survival rate was 98.2% at 12 months, 89.5% at 24 months, and 84.5% at 5 years. CONCLUSIONS: Endovascular therapy for proximal subclavian arterial obstructive lesions is effective and successful. This minimally invasive treatment may be the first choice of treatment for proximal subclavical arterial obstructive lesions.
Asunto(s)
Arteriopatías Oclusivas/terapia , Arteria Subclavia/patología , Adulto , Anciano , Anciano de 80 o más Años , Arteriopatías Oclusivas/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/terapia , Insuficiencia Vertebrobasilar/patología , Insuficiencia Vertebrobasilar/terapiaRESUMEN
Coronary-subclavian steal (CSS) is an increasingly reported phenomenon after coronary artery bypass graft (CABG) operation and it is caused by proximal subclavian artery stenosis in patients with internal thoracic artery grafts. We discuss briefly the diagnostic strategies to rule out significant subclavian stenosis before CABG and, in the follow-up, the importance of subclinical detection of coronary-subclavian steal before the potential onset of myocardial ischemia. Although the most appropriate management of concomitant brachiocephalic and coronary artery disease remains a matter of debate, patients developing CSS syndrome after CABG can be treated successfully by both surgical and percutaneous techniques. Retrospective analysis of surgical databases will help to identify the predictors, if any, of subclavian artery disease progression in candidates for internal thoracic artery grafting, in order to choose a tailored surgical approach.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Isquemia Miocárdica/etiología , Síndrome del Robo de la Subclavia/etiología , Anciano , Angiografía Coronaria , Femenino , Humanos , Isquemia Miocárdica/patología , Isquemia Miocárdica/terapia , Stents , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/terapia , Tomografía Computarizada de Emisión de Fotón ÚnicoRESUMEN
Coronary-subclavian steal through the left internal mammary graft is a rare cause of myocardial ischemia in patients who have had a coronary bypass surgery. We report a 70-year-old man who presented with sustained monomorphic ventricular tachycardia 5 years after the surgical creation of a left internal mammary to the left anterior descending artery. Cardiac catheterization illustrated that the left subclavian artery was occluded proximally and that the distal course was visualized by retrograde filling through the left internal mammary graft. Clinical ventricular tachycardia was reproducibly induced with a single ventricular extrastimulus, and antitachycardia pacing terminated the tachycardia. Restoration of blood flow by way of a Dacron graft placed between the descending aorta and the subclavian artery resulted in the total relief of symptoms. Ventricular tachycardia could not be induced during the control electrophysiologic study after surgical revascularization.
Asunto(s)
Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/patología , Síndrome del Robo de la Subclavia/diagnóstico , Síndrome del Robo de la Subclavia/patología , Taquicardia Ventricular/patología , Anciano , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/etiología , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Síndrome del Robo de la Subclavia/etiologíaRESUMEN
Subclavian steal is a well-described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.
Asunto(s)
Enfermedades de las Arterias Carótidas/patología , Enfermedades de las Arterias Carótidas/cirugía , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/cirugía , Enfermedades de las Arterias Carótidas/fisiopatología , Angiografía Cerebral , Diagnóstico Diferencial , Femenino , Lateralidad Funcional , Humanos , Persona de Mediana Edad , Stents , Síndrome del Robo de la Subclavia/fisiopatología , Resultado del TratamientoRESUMEN
Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.
Asunto(s)
Angioplastia de Balón/instrumentación , Vasos Coronarios/cirugía , Stents , Síndrome del Robo de la Subclavia/terapia , Procedimientos Quirúrgicos Vasculares , Adulto , Anciano , Anciano de 80 o más Años , Aleaciones , Angioplastia de Balón/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Diseño de Prótesis , Estudios Retrospectivos , Síndrome del Robo de la Subclavia/patología , Síndrome del Robo de la Subclavia/fisiopatología , Síndrome del Robo de la Subclavia/cirugía , Factores de Tiempo , Insuficiencia del Tratamiento , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
A previously healthy 22-year-old man presented with thoracic outlet syndrome manifesting as Raynaud's phenomenon in the left hand and embolic occlusion of the basilar artery. Three-dimensional computed tomography angiography showed that the left subclavian artery was occluded as it passed over the abnormal first rib. Retrograde propagation of the thrombus from the site of arterial occlusion and/or reflux of embolic material was suspected. Medical therapy was started. The patient underwent resection of the anomalous rib. Postoperative angiography demonstrated that the subclavian artery was recanalized with almost normal distal flow. The basilar artery was also recanalized. Thoracic outlet syndrome due to a first rib anomaly may cause stroke.
Asunto(s)
Embolia Intracraneal/etiología , Embolia Intracraneal/patología , Costillas/anomalías , Síndrome del Robo de la Subclavia/complicaciones , Insuficiencia Vertebrobasilar/etiología , Insuficiencia Vertebrobasilar/patología , Enfermedad Aguda/terapia , Anticoagulantes/uso terapéutico , Cerebelo/irrigación sanguínea , Cerebelo/patología , Angiografía Cerebral , Lateralidad Funcional/fisiología , Humanos , Embolia Intracraneal/diagnóstico por imagen , Imagen por Resonancia Magnética , Masculino , Flujo Sanguíneo Regional/fisiología , Costillas/diagnóstico por imagen , Costillas/cirugía , Síndrome del Robo de la Subclavia/etiología , Síndrome del Robo de la Subclavia/patología , Síndrome del Desfiladero Torácico/complicaciones , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/etiología , Procedimientos Quirúrgicos Torácicos , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Arteria Vertebral/diagnóstico por imagen , Arteria Vertebral/fisiopatología , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Adulto JovenRESUMEN
Intrathoracic carotid bifurcation is rare with only five other cases reported. This anatomic variant with posteromedial origin of the internal carotid artery (ICA) appears to be part of the Klippel-Feil syndrome, a rare congenital defect characterized by fusion of the cervical vertebrae. Caution is advised when planning thoracic and cervical vascular procedures. Angiography carries higher risk of unintentional ICA catheterization due to the short common carotid artery length. The intrathoracic location of the carotid bifurcation makes endarterectomy difficult and patients may do better with carotid artery stenting. Ultrasound can be confusing in these patients and MRA may be preferable.
Asunto(s)
Arteriopatías Oclusivas/patología , Tronco Braquiocefálico/patología , Arteria Carótida Interna/anomalías , Síndrome de Klippel-Feil/patología , Síndrome del Robo de la Subclavia/patología , Adulto , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular , Tronco Braquiocefálico/cirugía , Arteria Carótida Interna/cirugía , Constricción Patológica , Femenino , Humanos , Síndrome de Klippel-Feil/complicaciones , Síndrome de Klippel-Feil/cirugía , Angiografía por Resonancia Magnética , Síndrome del Robo de la Subclavia/complicaciones , Síndrome del Robo de la Subclavia/cirugía , Resultado del TratamientoRESUMEN
Coronary subclavian steal syndrome refers to decreased or reversed internal mammary artery flow, which causes angina related to severe subclavian steno-occlusive disease in patients with in situ internal mammary-to-coronary artery graft. We report a case, the first in the literature, of a right internal mammary artery-coronary-subclavian unidirectional steal syndrome. Clinical features, pathophysiology, and diagnostic and therapeutic strategies of this unusual adverse event are discussed.