Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists
Section snippets
Epidemiology
The prevalence of left subclavian stenosis in the general population is low and has been reported to be approximately 1.5%. The prevalence increases with the presence of atherosclerotic disease risk factors. Among patients with known PAD, the prevalence has been reported to be over 11%1; in one series this prevalence was reported as high as 42%.2 Additionally, among patients with brachiocephalic artery disease, approximately 50% have coronary artery disease (CAD), and 30% have carotid or
Anatomy
Among patients with left sided aortic arches, the brachiocephalic or innominate artery is the first branch after the origins of the coronary arteries. The brachiocephalic artery gives rise to the right common carotid artery and then continues as the right subclavian artery. The first branch of the right subclavian artery is the right vertebral artery. The aortic arch then continues and gives rise to the left carotid artery and finally the left subclavian artery.6 The vertebral arteries converge
Etiology
The most common etiology of subclavian stenosis is atherosclerosis. Other reported etiologies are listed in Table 2.8,12 Risk factors for the development of atherosclerotic subclavian stenosis include traditional CVD risk factors: smoking, low high-density lipoprotein cholesterol, smoking, and type 2 diabetes. Additional risk factors include lower extremity PAD and CAD.12 Congenital abnormalities associated with subclavian steal syndrome include hypoplasia of the proximal portion of the left
Diagnosis
The diagnosis of subclavian stenosis among symptomatic patients is first based on the history of ischemic symptoms predicted by the anatomy. The cornerstone for screening patients for brachiocephalic disease is measuring bilateral arm blood pressures (BPs). Among patients planning to undergo CABG, a BP difference between the left and right arms of 10 mmHg is suspicious for subclavian stenosis.1 A BP differential of 15 mmHg is highly predictive.15 With the appropriate clinical history and a
Medical treatment
Guideline directed medical treatment is indicated in patients with atherosclerotic brachiocephalic and subclavian stenosis for both symptomatic and asymptomatic patients. Medical treatment generally does not relieve symptoms, but its goal is to prevent the increased CVD mortality associated with the disease5 as well as to prevent disease progression. Guideline directed medical therapy of atherosclerosis involves anti-platelet therapy, lipid-lowering therapy (statins), control of hypertension
Endovascular and surgical treatment
Endovascular and surgical treatment of brachiocephalic and subclavian stenosis is indicated to relieve symptoms or to preserve flow to a CABG. It is contra-indicated if patients are free of symptoms from the stenosis.17
Contemporary endovascular treatment of brachiocephalic and subclavian artery stenosis involves balloon dilation of the stenosis followed by stent placement. The common femoral artery is the most commonly utilized access site for interventions. Brachial artery access may be used
Conclusion
Brachiocephalic and subclavian artery stenoses are less common than lower extremity manifestations of PAD. However, disease of these vessels is associated with increased CVD mortality. Therefore, the diagnosis and medical management of these patients is important, even when asymptomatic. Among asymptomatic patients undergoing CABG or those who develop symptoms, treatment is indicated. Endovascular therapy is generally preferred due to its lower co-morbidity and excellent late patency.
Declaration of Competing Interest
White None.
Patel: Abiomed – speaker; LivaNova – speaker; Boston Scientific - speaker.
References (26)
- et al.
The vital prognosis of subclavian stenosis
J. Am. Coll. Cardiol.
(2007) - et al.
Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases
J. Am. Coll. Cardiol.
(2004) - et al.
Congenital subclavian steal syndrome: anatomy, physiology, pathology and surgical correction
Chest
(1974) - et al.
Congenital subclavian steal syndrome with anomaly of the aortic arch
Surg. Neurol.
(1993) - et al.
Long-term results of 81 prevertebral subclavian artery angioplasties: a 26-year experience
Ann. Vasc. Surg.
(2011) Technique for subclavian to carotid transposition, tips, and tricks
J. Vasc. Surg.
(2009)- et al.
Long-term results with axillo-axillary bypass grafts for symptomatic subclavian artery insufficiency
J. Vasc. Surg.
(1997) - et al.
Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization
Catheter. Cardiovasc. Interv.
(2001) - et al.
Prevalence of subclavian artery stenosis in patients with peripheral vascular disease
Angiology
(2001) - et al.
Primary stenting of subclavian and innominate artery occlusive disease: a single center’s experience
Cardiovasc. Intervent. Radiol.
(2004)
Determinants of immediate and long-term results of subclavian and innominate artery angioplasty
Catheter. Cardiovasc. Interv.
Congenital variants and anomalies of the aortic arch
Radiographics
Basic vascular neuroanatomy of the brain and spine: what the general interventional radiologist needs to know
Semin. Interv. Radiol.
Cited by (6)
Clinical outcomes of a balloon-expandable stent for symptomatic obstructions of the subclavian or innominate arteries
2023, Vasa - European Journal of Vascular MedicineSafety of bilateral arm pressure measurements in the diagnostic workup of dialysis-associated steal syndrome
2023, Journal of Vascular AccessCardiac and Vascular Causes of Syncope and Atherosclerosis
2022, Current Cardiology ReportsEndovascular therapy for steno-occlusive subclavian artery disease early and long-term outcomes in a multicentric Tunisian study
2022, Annali Italiani di Chirurgia