Subclavian Steal A 12-Year Charles D.
Syndrome
Experience
Hafner,
MD
\s=b\ Over a 12-year period, 43 operations were performed on 40 patients for correction of the subclavian steal syndrome. Eleven of these patients also underwent endarterectomy for coexisting carotid artery disease. There were 16 transthoracic procedures and 27 transcervical procedures. Graft failure in two patients was corrected by a second operation. There was one early death and one late death. The remaining 38 patients have been carefully studied for up to 12 years, with an average follow-up period of 60 months. These 38 patients have remained asymptomatic and their revascularization procedures have remained functional, as determined by blood pressure determinations in the involved extremity and, in some cases, by arteriography. (Arch Surg 111:1074-1080, 1976)
namely the vertebrovertebral circulation
Fig 1.—Distribution of occlusive syndrome.
flow through the vertebral artery was first demonstrated by arteriography in 1960 by Contorni1 of Soon after, in 1961, Reivich et al7 reported additional angiographie evidence of reversal in vertebral artery blood flow, associated with neurological symptoms. It was in the same journal that the name "subclavian steal syndrome" was coined in an editorial by C. Miller Fisher.7 Hemodynamic reversal in the vertebral artery, however, was recognized clinically as early as 1837 by Liston when he attempted ligational therapy for an aneurysm of the subclavian artery. Later, in 1864, Smyth7' understood the underlying cause of syncope and hemorrhage following ligational therapy for an aneurysm of the right subclavian artery. He recognized also that proximal ligation resulted in reversal of flow through the ipsilateral vertebral artery. As early as 1829, Harrison" mentions retrograde flow through the vertebral artery to supply the subclavian artery with proximal obstruction. Therefore, the primary hemodynamic alterations in the subclavian steal syndrome,
Retrograde Italy.
'
Accepted
From the
nati.
publication March 31, 1976. Department of Surgery, Good
for
Reprint requests
to 311 Howell
Samaritan
as a
compensa¬
tory system for occlusion of the first part of the subclavian artery, had been specifically identified early in the 19th century. It is generally recognized at the present time that reversal of flow can occur in any artery of the body that is occluded proximally. However, it should be mentioned that
Hospital, Cincin-
Ave, Cincinnati, OH 45220 (Dr Hafner).
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
lesions
causing
subclavian steal
Fig 2.—Left, Occlusion at vertebral artery.
as
long
ago
as
origin
of
1664, Willis7
reversal of flow could
occur
right
was
subclavian
artery (arrow). Right, Arrow indicates retrograde flow of contrast material in right
perfectly
aware
in the carotid arteries and
indeed, demonstrated this experimentally.
that
had,
Hemodynamic reversal in
ever, results in
the vertebral artery rarely, if permanent neurological deficits, as indi¬
cated by this study and by the study of Fields.s Indeed, the condition may be entirely asymptomatic. Nevertheless, disabling symptoms of cerebral vascular insufficiency and ischemie symptoms of the involved upper extremity are frequently present. Surgical treatment seems to be indi¬ cated for the relief of these disabling symptoms and to improve total intracranial blood flow, particularly when there are other associated occlusive lesions affecting the cerebral circulation. Ipsilateral vertebral artery ligation has been advocated as a simple method of surgical inter¬ vention by Rob." Although this is a consideration for the extremely poor-risk patient, it is generally believed that cerebral circulation should be preserved and improved by revascularization procedures whenever possible.
SUBJECTS Over the past 12 years, 43 operations have been performed on 40 There were two reoperations. one for early graft failure and one for late graft failure. There was one bilateral procedure. Twenty-two of the patients were women, with an age range of from 39 to 72 years and an average age of 52 years. There were 18 men ranging in age from 42 to 69 years, an average of 58 years. There was a strong predilection towards left side involvement (30 patients) as compared to the right side (11 patients) (Fig 1). The diagnosis essentially was made on clinical evaluation, but confirmed by angiography (Fig 2 through 4). The most common symptoms were vertigo, syncope, intermittent claudication in the involved upper extremity, and visual disturbances (Table). Twenty-six (65%) of the patients experienced vertigo; in 16 patients (40%), the vertigo was severe enough to result in complete syncopal attacks. The constant physical finding was a reduction in blood pressure on the ipsilateral upper extremity; the difference between the two upper extremities ranged from 30 to 150 mm Hg. The ipsilateral subclavian pulse was not palpable, and the radial pulse was either absent or diminished with a slight lag as com-
patients.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
pared to the opposite side. Only rarely could the classical sign of this syndrome, namely, basilar artery insufficiency symptoms elicited by exercising the ipsilateral upper extremity, be demon¬ strated. A supraclavicular systolic bruit was present in some patients, but absent in others. Other associated cerebral vascular lesions were present in 19 of the 40 patients. In those patients who experienced transient ischemie attacks or monocular blindness,
the associated carotid artery lesions wTere considered to be the underlying cause. Only 16 (40%) of the patients complained of intermittent claudication of the ipsilateral upper extremity. Four of these patients had severe disabling claudication. It is of particular interest that four patients had advanced ischemie symptoms of the hand. This perhaps indicates insufficient collat¬ eral blood flow; however, it is possible .that this unusual degree of arterial insufficiency is the result of distal embolization from the primary occlusive lesion.
TREATMENT
Twenty-seven patients underwent transcervical procedures and 16 underwent transthoracic procedures. Of the 27 transcervical operations, the most common procedure was the common carotid artery to subclavian artery saphenous vein bypass graft1" (Fig 5). It was necessary to use a prosthetic bypass in two patients because the saphenous vein was unsuitable. Three patients underwent transcervical subclavian endarterectomy, because the occlusive lesion was very close to or involving the orifice of the vertebral artery. The thoracic approach to the left side was a standard posterior lateral incision through the fourth or fifth intercostal space, or through the bed of the resected fifth rib. The thoracic approach for occlusion of the innominate artery was a sternal-splitting incision down to the third interspace and then extending this line into the right third interspace as previously reported." An 8-mm woven crimped Dacron prosthesis replacement was used in all instances (Fig 6). Endarterectomy of the intrathoracic arteries was avoided except in two instances, in which the lesion extended well into the left subclavian artery near the orifice of the vertebral artery. In these cases, a limited distal endarterectomy was combined with a prosthetic replacement. The transthoracic approach is technically easy to perform because the exposure is excellent and one is dealing with larger arteries and larger anastomoses. It appears from this study that exceptionally good, and possibly better, hemodynamics are achieved by the replacement of these larger arteries in the thorax, in comparison to results achieved by transcervical bypasses. However, only the younger, good-risk patients should be considered for this approach. In those instances in which the innominate artery is occluded, and in those few cases in which both the left common carotid and the left subclavian arteries are occluded, it appears that the transthoracic approach is more favorable as long as there are no contraindications to the magnitude of this procedure. If, however, the patient is elderly or an increased operative risk, some compromise procedure, such as the crossover subclavian to subclavian bypass," the axillary to axillary bypass," or the femoral to axillary bypass," should be considered. The transcervical approach for correction of the subclavian steal syndrome is easily tolerated by the elderly and the poor-risk patient. An autogenous saphenous vein bypass has been the operation of choice in this study. In addition, this procedure can be combined with an ipsilateral carotid endarterectomy. This has been achieved through two separate incisions, one for exposure of the carotid bifurcation and the second for exposure of the subclavian artery. The vein graft is inserted through a tunnel between the two incisions. Seven of 40 patients underwent
Fig 3.—Retrograde
flow in left vertebral
artery.
simultaneous carotid endarterectomy and saphenous vein bypass graft for correction of the steal syndrome. In addition, four of the 40 patients underwent staged procedures in which the carotid endarterectomy was performed in a separate operation. Of special interest is the patient in this group of 40 who experienced the sudden onset of severe blurring of vision and almost complete syncope while driving his car. This occurred as the result of an acute dissection of an innominate artery aneurysm that occluded the right common carotid artery and caused a sudden reversal of flow in the right vertebral artery. After stabilization of his general condition and his cerebral ischemia, the innominate aneurysm was resected and replaced with a bifurca¬ tion Dacron prosthesis. This patient has remained well and asymptomatic for 27 months. Another patient experienced symptoms as the result of chronic occlusion at the origins of both the left common carotid artery and the left subclavian artery. During a transthoracic procedure an aortosubclavian Dacron prosthesis was inserted. However, the left common carotid artery was completely obliterated throughout its intrathoracic course. In a later transcervical operation a Dacron
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Fig 4.—Top left, Occlusion of right and left subclavian arteries and stenosis of left carotid artery (arrows). (Patient had bilateral vertebral artery retrograde flow.) Top right, Functioning left common carotid artery to left subclavian artery vein bypass graft (arrows). Bottom, Left vertebral to right vertebral flow after operative intervention on the left side. (Right side corrected by second operation.)
Symptoms Vertigo Syncope Intermittent claudication Visual disturbances
Blurring Scotomata Blindness* Headache Transient paralysis" Ataxia Ischemia of hand
_
in 40 Patients No. (%) of Patients 26 (65) 16 (40) 16 (40) 19 (47) 10
11 9 4
(27) (22) (10) 4 (10)
"In 12 of 14 patients with transient paralysis or monocular blindness, associated carotid lesions were considered the probable cause.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Fig 5.—Top, Operative exposure for transcervical procedure. Bottom, Common artery to subclavian artery saphenous vein bypass graft.
carotid
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
was inserted successfully from the revascularized left subclavian artery to the left common carotid artery bifurcation. This patient has remained asymptomatic for eight years.
prosthesis
RESULTS
One patient died 30 hours postoperatively as a result of cerebral infarction on the side opposite to the surgical procedure. This was a desperation case, and in retrospect, this patient should not have been operated on. Both of his carotid arteries were permanently and completely oc¬ cluded, and it was hoped that correction of the subclavian steal on the right side would improve his condition. He tolerated a transcervical vein bypass procedure well, and had recovered from anesthesia without any neurological deficits. However, 30 hours later a fatal cerebral infarction on the opposite side developed. A second patient died nine
Fig 6.—Right,
Transthoracic Dacron
prosthesis replacement.
Fig 7.—Postoperative angiogram at patency of Dacron prosthesis (arrow) right subclavian artery.
11 years demonstrating from ascending aorta to
Fig 8.—Postoperative angiogram at 60 months demonstrating functioning left common carotid artery to left subclavian artery vein bypass graft.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
months postoperatively of a myocardial infarction. There was one early vein graft failure in the immediate postoperative period, due to profound and uncontrolled hypotension during and after the operative procedure. When the patient's condition was stabilized six days later she was reoperated on. No technical problems could be found to explain the occlusion. A thrombectomy was performed and the saphenous vein bypass has remained functioning for 57 months. There was one late failure of a transcervical Dacron prosthesis at 22 months, resulting in a return of the patient's symptoms of severe vertigo and syncope. A difference in blood pressure of 80 mm Hg between the upper extremities indicated occlusion of the graft, and this was confirmed by arteriography. The patient was reoperated on and a Dacron prosthesis was inserted by means of the transthoracic route. This graft has remained patent for 61 months. Thirty-eight patients, therefore, have remained alive, well, and asymptomatic. They have been followed up for a period of from 15 months to 12 years, with an average follow-up of 60 months. Graft patency has been determined
by clinical observations of the blood pressure and arterial pulses of the involved extremity, and by continued relief of symptoms. Postoperative angiograms also have been use¬ ful in demonstrating functioning grafts (Fig 7 and 8). COMMENT
Retrograde flow through the vertebral artery has been recognized since the early part of the 19th century, but had not been demonstrated by arteriography until 1960. This hemodynamic reversal rarely, if ever, results in permanent neurological deficits and, indeed, may be asymptomatic. However, when disabling symptoms are present, surgical intervention is indicated. Although the transthoracic approach was the most popular during the earlier years, this operation should now be reserved for the young, goodrisk patient or for unusual circumstances. Extrathoracic procedures should'be utilized for the elderly and poor-risk patient. Simple vertebral artery ligation should be avoided when it is at all possible to improve intracranial blood flow by means of a revascularization procedure.
References 1. Contorni L: Il circolo collaterale vertebro-vertebrale nella obliterazione dell' arteria subclavia alla sua origine. Minerva Chir 15:268-271, 1960. 2. Reivich M, Holling HE, Roberts B, et al: Reversal of blood flow through vertebral artery and its effect on cerebral circulation. N Engl J Med 265:878\x=req-\ 885, 1961. 3. Fisher CM: New vascular syndrome, "subclavian steal." N Engl J Med 265:912-913, 1961. 4. Liston RL: Aneurysm of the right subclavian artery (ligature of the subclavian and carotid arteries). Lancet 2:668-669, 1838. 5. Smyth AW: Successful operation in a case of subclavian aneurysm. New Orleans Med Rec 1, May 15, 1866, p 4. 6. Harrison P: The Surgical Anatomy of the Arteries of the Human Body. Dublin, Hodges & Smith, 1827. 7. Willis T: Cerebri anatome cui accessit nervorum descriptio et usua. Londini, Typis J. Flescher, 1664.
8. Fields WS: Joint study of extracranial arterial occlusion: VII. Subclavian steal: A review of 168 cases. JAMA 222:1139-1143, 1972. 9. Rob CG: Incipient Stroke: Technique of Surgical Therapy. New York, Grune & Stratton Inc, 1961. 10. North RR, Fields WS, DeBakey ME, et al: Brachial-basilar insufficiency syndrome. Neurology 12:810-820, 1962. 11. Hafner CD: Cerebrovascular insufficiency, in Cranley JJ (ed): Vascular Surgery. New York, Harper & Row Publishers, 1972, vol 1, p 81. 12. Ehrenfeld WK, Levin SM, Wylie EJ: Venous crossover bypass grafts for arterial insufficiency. Ann Surg 167:287-291, 1968. 13. Jacobson JH II, Mozersky DJ, Mitty HA, et al: Axillary-axillary bypass for the "subclavian steal" syndrome. Arch Surg 106:24-27, 1973. 14. Sproul G: Femoral-axillary bypass for cerebral vascular insufficiency. Arch Surg 103:746-747, 1971.
Invited Editorial Comment The author describes an impressive and interesting experience, particularly in view of the fact that this goes back over a 12-year period. It is of interest also that 11 of the 40 patients had coexisting carotid artery disease requiring endarterectomy. The author is quite correct in stating that subclavian steal syndrome rarely if ever results in a permanent neurologic deficit. It is probably more common today to treat patients with carotid and vertebral artery disease via restoration of circulation to the carotid first, for reconstruction of this is usually adequate to
relieve symptoms of reversal of flow. Many vascular surgeons believe that vertebral basilar reconstruction is necessary only in those patients who have not responded to restoration of carotid flow, or who have isolated vertebral artery disease. Probably the preferred operation for subclavian restoration is a cross-cervical axilloaxillary bypass graft rather than the more difficult and hazardous transthoracic aortosubclavian bypass graft. Allan D. Callow, MD Boston
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Syndrome
Experience
Hafner,
MD
\s=b\ Over a 12-year period, 43 operations were performed on 40 patients for correction of the subclavian steal syndrome. Eleven of these patients also underwent endarterectomy for coexisting carotid artery disease. There were 16 transthoracic procedures and 27 transcervical procedures. Graft failure in two patients was corrected by a second operation. There was one early death and one late death. The remaining 38 patients have been carefully studied for up to 12 years, with an average follow-up period of 60 months. These 38 patients have remained asymptomatic and their revascularization procedures have remained functional, as determined by blood pressure determinations in the involved extremity and, in some cases, by arteriography. (Arch Surg 111:1074-1080, 1976)
namely the vertebrovertebral circulation
Fig 1.—Distribution of occlusive syndrome.
flow through the vertebral artery was first demonstrated by arteriography in 1960 by Contorni1 of Soon after, in 1961, Reivich et al7 reported additional angiographie evidence of reversal in vertebral artery blood flow, associated with neurological symptoms. It was in the same journal that the name "subclavian steal syndrome" was coined in an editorial by C. Miller Fisher.7 Hemodynamic reversal in the vertebral artery, however, was recognized clinically as early as 1837 by Liston when he attempted ligational therapy for an aneurysm of the subclavian artery. Later, in 1864, Smyth7' understood the underlying cause of syncope and hemorrhage following ligational therapy for an aneurysm of the right subclavian artery. He recognized also that proximal ligation resulted in reversal of flow through the ipsilateral vertebral artery. As early as 1829, Harrison" mentions retrograde flow through the vertebral artery to supply the subclavian artery with proximal obstruction. Therefore, the primary hemodynamic alterations in the subclavian steal syndrome,
Retrograde Italy.
'
Accepted
From the
nati.
publication March 31, 1976. Department of Surgery, Good
for
Reprint requests
to 311 Howell
Samaritan
as a
compensa¬
tory system for occlusion of the first part of the subclavian artery, had been specifically identified early in the 19th century. It is generally recognized at the present time that reversal of flow can occur in any artery of the body that is occluded proximally. However, it should be mentioned that
Hospital, Cincin-
Ave, Cincinnati, OH 45220 (Dr Hafner).
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
lesions
causing
subclavian steal
Fig 2.—Left, Occlusion at vertebral artery.
as
long
ago
as
origin
of
1664, Willis7
reversal of flow could
occur
right
was
subclavian
artery (arrow). Right, Arrow indicates retrograde flow of contrast material in right
perfectly
aware
in the carotid arteries and
indeed, demonstrated this experimentally.
that
had,
Hemodynamic reversal in
ever, results in
the vertebral artery rarely, if permanent neurological deficits, as indi¬
cated by this study and by the study of Fields.s Indeed, the condition may be entirely asymptomatic. Nevertheless, disabling symptoms of cerebral vascular insufficiency and ischemie symptoms of the involved upper extremity are frequently present. Surgical treatment seems to be indi¬ cated for the relief of these disabling symptoms and to improve total intracranial blood flow, particularly when there are other associated occlusive lesions affecting the cerebral circulation. Ipsilateral vertebral artery ligation has been advocated as a simple method of surgical inter¬ vention by Rob." Although this is a consideration for the extremely poor-risk patient, it is generally believed that cerebral circulation should be preserved and improved by revascularization procedures whenever possible.
SUBJECTS Over the past 12 years, 43 operations have been performed on 40 There were two reoperations. one for early graft failure and one for late graft failure. There was one bilateral procedure. Twenty-two of the patients were women, with an age range of from 39 to 72 years and an average age of 52 years. There were 18 men ranging in age from 42 to 69 years, an average of 58 years. There was a strong predilection towards left side involvement (30 patients) as compared to the right side (11 patients) (Fig 1). The diagnosis essentially was made on clinical evaluation, but confirmed by angiography (Fig 2 through 4). The most common symptoms were vertigo, syncope, intermittent claudication in the involved upper extremity, and visual disturbances (Table). Twenty-six (65%) of the patients experienced vertigo; in 16 patients (40%), the vertigo was severe enough to result in complete syncopal attacks. The constant physical finding was a reduction in blood pressure on the ipsilateral upper extremity; the difference between the two upper extremities ranged from 30 to 150 mm Hg. The ipsilateral subclavian pulse was not palpable, and the radial pulse was either absent or diminished with a slight lag as com-
patients.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
pared to the opposite side. Only rarely could the classical sign of this syndrome, namely, basilar artery insufficiency symptoms elicited by exercising the ipsilateral upper extremity, be demon¬ strated. A supraclavicular systolic bruit was present in some patients, but absent in others. Other associated cerebral vascular lesions were present in 19 of the 40 patients. In those patients who experienced transient ischemie attacks or monocular blindness,
the associated carotid artery lesions wTere considered to be the underlying cause. Only 16 (40%) of the patients complained of intermittent claudication of the ipsilateral upper extremity. Four of these patients had severe disabling claudication. It is of particular interest that four patients had advanced ischemie symptoms of the hand. This perhaps indicates insufficient collat¬ eral blood flow; however, it is possible .that this unusual degree of arterial insufficiency is the result of distal embolization from the primary occlusive lesion.
TREATMENT
Twenty-seven patients underwent transcervical procedures and 16 underwent transthoracic procedures. Of the 27 transcervical operations, the most common procedure was the common carotid artery to subclavian artery saphenous vein bypass graft1" (Fig 5). It was necessary to use a prosthetic bypass in two patients because the saphenous vein was unsuitable. Three patients underwent transcervical subclavian endarterectomy, because the occlusive lesion was very close to or involving the orifice of the vertebral artery. The thoracic approach to the left side was a standard posterior lateral incision through the fourth or fifth intercostal space, or through the bed of the resected fifth rib. The thoracic approach for occlusion of the innominate artery was a sternal-splitting incision down to the third interspace and then extending this line into the right third interspace as previously reported." An 8-mm woven crimped Dacron prosthesis replacement was used in all instances (Fig 6). Endarterectomy of the intrathoracic arteries was avoided except in two instances, in which the lesion extended well into the left subclavian artery near the orifice of the vertebral artery. In these cases, a limited distal endarterectomy was combined with a prosthetic replacement. The transthoracic approach is technically easy to perform because the exposure is excellent and one is dealing with larger arteries and larger anastomoses. It appears from this study that exceptionally good, and possibly better, hemodynamics are achieved by the replacement of these larger arteries in the thorax, in comparison to results achieved by transcervical bypasses. However, only the younger, good-risk patients should be considered for this approach. In those instances in which the innominate artery is occluded, and in those few cases in which both the left common carotid and the left subclavian arteries are occluded, it appears that the transthoracic approach is more favorable as long as there are no contraindications to the magnitude of this procedure. If, however, the patient is elderly or an increased operative risk, some compromise procedure, such as the crossover subclavian to subclavian bypass," the axillary to axillary bypass," or the femoral to axillary bypass," should be considered. The transcervical approach for correction of the subclavian steal syndrome is easily tolerated by the elderly and the poor-risk patient. An autogenous saphenous vein bypass has been the operation of choice in this study. In addition, this procedure can be combined with an ipsilateral carotid endarterectomy. This has been achieved through two separate incisions, one for exposure of the carotid bifurcation and the second for exposure of the subclavian artery. The vein graft is inserted through a tunnel between the two incisions. Seven of 40 patients underwent
Fig 3.—Retrograde
flow in left vertebral
artery.
simultaneous carotid endarterectomy and saphenous vein bypass graft for correction of the steal syndrome. In addition, four of the 40 patients underwent staged procedures in which the carotid endarterectomy was performed in a separate operation. Of special interest is the patient in this group of 40 who experienced the sudden onset of severe blurring of vision and almost complete syncope while driving his car. This occurred as the result of an acute dissection of an innominate artery aneurysm that occluded the right common carotid artery and caused a sudden reversal of flow in the right vertebral artery. After stabilization of his general condition and his cerebral ischemia, the innominate aneurysm was resected and replaced with a bifurca¬ tion Dacron prosthesis. This patient has remained well and asymptomatic for 27 months. Another patient experienced symptoms as the result of chronic occlusion at the origins of both the left common carotid artery and the left subclavian artery. During a transthoracic procedure an aortosubclavian Dacron prosthesis was inserted. However, the left common carotid artery was completely obliterated throughout its intrathoracic course. In a later transcervical operation a Dacron
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Fig 4.—Top left, Occlusion of right and left subclavian arteries and stenosis of left carotid artery (arrows). (Patient had bilateral vertebral artery retrograde flow.) Top right, Functioning left common carotid artery to left subclavian artery vein bypass graft (arrows). Bottom, Left vertebral to right vertebral flow after operative intervention on the left side. (Right side corrected by second operation.)
Symptoms Vertigo Syncope Intermittent claudication Visual disturbances
Blurring Scotomata Blindness* Headache Transient paralysis" Ataxia Ischemia of hand
_
in 40 Patients No. (%) of Patients 26 (65) 16 (40) 16 (40) 19 (47) 10
11 9 4
(27) (22) (10) 4 (10)
"In 12 of 14 patients with transient paralysis or monocular blindness, associated carotid lesions were considered the probable cause.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
Fig 5.—Top, Operative exposure for transcervical procedure. Bottom, Common artery to subclavian artery saphenous vein bypass graft.
carotid
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
was inserted successfully from the revascularized left subclavian artery to the left common carotid artery bifurcation. This patient has remained asymptomatic for eight years.
prosthesis
RESULTS
One patient died 30 hours postoperatively as a result of cerebral infarction on the side opposite to the surgical procedure. This was a desperation case, and in retrospect, this patient should not have been operated on. Both of his carotid arteries were permanently and completely oc¬ cluded, and it was hoped that correction of the subclavian steal on the right side would improve his condition. He tolerated a transcervical vein bypass procedure well, and had recovered from anesthesia without any neurological deficits. However, 30 hours later a fatal cerebral infarction on the opposite side developed. A second patient died nine
Fig 6.—Right,
Transthoracic Dacron
prosthesis replacement.
Fig 7.—Postoperative angiogram at patency of Dacron prosthesis (arrow) right subclavian artery.
11 years demonstrating from ascending aorta to
Fig 8.—Postoperative angiogram at 60 months demonstrating functioning left common carotid artery to left subclavian artery vein bypass graft.
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
months postoperatively of a myocardial infarction. There was one early vein graft failure in the immediate postoperative period, due to profound and uncontrolled hypotension during and after the operative procedure. When the patient's condition was stabilized six days later she was reoperated on. No technical problems could be found to explain the occlusion. A thrombectomy was performed and the saphenous vein bypass has remained functioning for 57 months. There was one late failure of a transcervical Dacron prosthesis at 22 months, resulting in a return of the patient's symptoms of severe vertigo and syncope. A difference in blood pressure of 80 mm Hg between the upper extremities indicated occlusion of the graft, and this was confirmed by arteriography. The patient was reoperated on and a Dacron prosthesis was inserted by means of the transthoracic route. This graft has remained patent for 61 months. Thirty-eight patients, therefore, have remained alive, well, and asymptomatic. They have been followed up for a period of from 15 months to 12 years, with an average follow-up of 60 months. Graft patency has been determined
by clinical observations of the blood pressure and arterial pulses of the involved extremity, and by continued relief of symptoms. Postoperative angiograms also have been use¬ ful in demonstrating functioning grafts (Fig 7 and 8). COMMENT
Retrograde flow through the vertebral artery has been recognized since the early part of the 19th century, but had not been demonstrated by arteriography until 1960. This hemodynamic reversal rarely, if ever, results in permanent neurological deficits and, indeed, may be asymptomatic. However, when disabling symptoms are present, surgical intervention is indicated. Although the transthoracic approach was the most popular during the earlier years, this operation should now be reserved for the young, goodrisk patient or for unusual circumstances. Extrathoracic procedures should'be utilized for the elderly and poor-risk patient. Simple vertebral artery ligation should be avoided when it is at all possible to improve intracranial blood flow by means of a revascularization procedure.
References 1. Contorni L: Il circolo collaterale vertebro-vertebrale nella obliterazione dell' arteria subclavia alla sua origine. Minerva Chir 15:268-271, 1960. 2. Reivich M, Holling HE, Roberts B, et al: Reversal of blood flow through vertebral artery and its effect on cerebral circulation. N Engl J Med 265:878\x=req-\ 885, 1961. 3. Fisher CM: New vascular syndrome, "subclavian steal." N Engl J Med 265:912-913, 1961. 4. Liston RL: Aneurysm of the right subclavian artery (ligature of the subclavian and carotid arteries). Lancet 2:668-669, 1838. 5. Smyth AW: Successful operation in a case of subclavian aneurysm. New Orleans Med Rec 1, May 15, 1866, p 4. 6. Harrison P: The Surgical Anatomy of the Arteries of the Human Body. Dublin, Hodges & Smith, 1827. 7. Willis T: Cerebri anatome cui accessit nervorum descriptio et usua. Londini, Typis J. Flescher, 1664.
8. Fields WS: Joint study of extracranial arterial occlusion: VII. Subclavian steal: A review of 168 cases. JAMA 222:1139-1143, 1972. 9. Rob CG: Incipient Stroke: Technique of Surgical Therapy. New York, Grune & Stratton Inc, 1961. 10. North RR, Fields WS, DeBakey ME, et al: Brachial-basilar insufficiency syndrome. Neurology 12:810-820, 1962. 11. Hafner CD: Cerebrovascular insufficiency, in Cranley JJ (ed): Vascular Surgery. New York, Harper & Row Publishers, 1972, vol 1, p 81. 12. Ehrenfeld WK, Levin SM, Wylie EJ: Venous crossover bypass grafts for arterial insufficiency. Ann Surg 167:287-291, 1968. 13. Jacobson JH II, Mozersky DJ, Mitty HA, et al: Axillary-axillary bypass for the "subclavian steal" syndrome. Arch Surg 106:24-27, 1973. 14. Sproul G: Femoral-axillary bypass for cerebral vascular insufficiency. Arch Surg 103:746-747, 1971.
Invited Editorial Comment The author describes an impressive and interesting experience, particularly in view of the fact that this goes back over a 12-year period. It is of interest also that 11 of the 40 patients had coexisting carotid artery disease requiring endarterectomy. The author is quite correct in stating that subclavian steal syndrome rarely if ever results in a permanent neurologic deficit. It is probably more common today to treat patients with carotid and vertebral artery disease via restoration of circulation to the carotid first, for reconstruction of this is usually adequate to
relieve symptoms of reversal of flow. Many vascular surgeons believe that vertebral basilar reconstruction is necessary only in those patients who have not responded to restoration of carotid flow, or who have isolated vertebral artery disease. Probably the preferred operation for subclavian restoration is a cross-cervical axilloaxillary bypass graft rather than the more difficult and hazardous transthoracic aortosubclavian bypass graft. Allan D. Callow, MD Boston
Downloaded From: http://archsurg.jamanetwork.com/ by a Monash University Library User on 06/19/2015
![[Carotid-subclavian steal syndrome].](/assets/img/hold.png)
