Elsevier

Progress in Cardiovascular Diseases

Volume 65, March–April 2021, Pages 44-48
Progress in Cardiovascular Diseases

Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists

https://doi.org/10.1016/j.pcad.2021.03.004Get rights and content

Abstract

Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes.

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.

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