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Subclavian steal syndrome is a compilation of symptoms that occur from a retrograde blood flow in vertebral arteries. This also includes retrograde blood flow of thoracic arteries, which can both be attributed to a nearby Subclavian artery stenosis, the occlusion or narrowing of subclavian arteries.
Symptoms of Subclavian steal syndrome can include any decreased neurological ability, any signs of fainting, presyncope (feeling that one is going to faint), or syncope (actually fainting).
Ways that Subclavian steal syndrome is diagnosed is testing to see any change or decrease in neurological activity, caused by cerebral ischemia, or the lack of blood flow to the brain. This is usually determined by a simple ipsilateral exercise of the arms. Another form of diagnosis of Subclavian steal syndrome is measuring the differential of blood pressure and flow between arms, and then determine if there is any difference. If so, it is then needed to be tested to see if this is due to pressure of any kind to the artery, stenosis, or any occlusion within the artery.
Synonym : Harrison and Smyth's syndrome, Subclavian Steal Syndrome, SSS.
The subclavian steal phenomenon (SSP) occurs when there is stenosis or occlusion of the subclavian artery proximal to the origin of the vertebral artery. This may cause flow reversal in the ipsilateral vertebral artery as blood is 'stolen' from the circular vertebro-basilar system, to supply the distal territory of the occluded or stenosed artery. Retrograde flow in the vertebral artery, associated with a subclavian or innominate (brachiocephalic) artery stenosis, can be an incidental finding during doppler US examination of the cerebral supply.
The term 'subclavian steal syndrome' should strictly be applied only to cases where this aberrant blood flow causes neurological symptoms. These are related to reduced cerebral perfusion when the arm ipsilateral to the subclavian stenosis is exercised.
Anatomy and blood flow in SSP
See image of normal anatomy of aortic arch and its branches.
Subclavian steal phenomenon affects the left side much more commonly than the right, with relative incidence about 3-4:1.2,3 This is due to anatomical differences that means the left subclavian artery is much more commonly affected by atherosclerosis.
Note, if the left vertebral artery arises directly from the aortic arch (as it does in 2% of population), stenosis of the proximal left subclavian artery cannot cause the syndrome because there is no communication between the vertebral and subclavian arteries.
Risk factors
As the majority of cases are due to atherosclerosis, risk factors for SSP are as for cardiovascular disease (CVD) in general :
In Asia, a significant proportion of SSP (36%) is caused by Takayasu's arteritis. These tend to present at a much earlier age (< 30 years) and have a female predominance.
Symptoms
Seek a history of a provoking event that is clearly linked to symptoms. These may be reproducible. Symptoms are usually related to vertebrobasilar and posterior cerebral circulation ischaemia.
On exercising the upper limb on the affected side, the patient may experience any of the following :
Neck movements may also cause symptoms.
Signs
Differential diagnosis
Investigations
Management
Angioplasty or surgery can both be used to bypass the stenosis of the subclavian artery. Both carry a risk of stroke and death - angioplasty 3.6%, surgery 0.4-2.4% (death only) and recurrent attacks follow surgical treatment in 10-24% of patients. Where symptoms are not severe, conservative management is usually recommended.
Prognosis
Symptoms may spontaneously resolve due to the establishment of extracranial collaterals to the subclavian circulation. This makes the decision to treat a symptomatic patient not clear cut: treatment is usually reserved for patients with debilitating vertebrobasilar transient ischaemic attacks.
More generally, subclavian stenosis is significantly associated with increased total and CVD-related death, independent of CVD risk factors and existent CVD at diagnosis.
Associated steal syndromes
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