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Subclavian Steal Syndrome Imaging

Practice Essentials

Subclavian steal syndrome (SSS) is a type of peripheral artery disease in which reduction or absence of flow in the proximal subclavian artery reverses the normal direction of blood flow in the vertebral artery. Blood is drawn from the contralateral vertebral, basilar, or carotid artery to provide flow in the affected subclavian artery distal to the stenosis.
 Subclavian steal phenomena (SSP) refers to retrograde flow in the vertebral artery only. The term SSS is reserved for retrograde vertebral artery flow associated with transient neurologic symptoms related to cerebral ischemia. 

Coronary subclavian steal syndrome (CSSS) is defined as retrograde flow in the internal mammary artery graft, after coronary artery bypass surgery (CABG), resulting in anterior wall myocardial ischemia.

The subclavian steal, in the absence of other anatomic anomalies, is usually asymptomatic and often an incidental finding. Rarely, however, some patients may provoke the syndrome with exercise and present with transient ipsilateral arm claudication, ataxia, and/or angina. 

Preferred examination

First diagnosed angiographically in the early 1960s, SSS is now most commonly diagnosed during Doppler ultrasound (US) examination of the neck arteries.
 Color Doppler US is the preferred examination for subclavian steal syndrome, but it is operator dependent. In addition, direct examination of the proximal subclavian artery is compromised by the overlying clavicle, ribs, and sternum.

CT and MR angiography are used to confirm any suspected subclavian steal cases found on ultrasound exams, because not all retrograde vertebral flow seen on ultrasound examinations constitute true subclavian steal. Some have been shown to stem from proximal vertebral artery stenosis or occlusion. These techniques can directly show the anatomic features of subclavian stenosis or occlusion, the presence of retrograde vertebral flow, and any associated extracranial and intracranial stenoses.

(See the images below of subclavian steal syndrome.)

Arch aortogram initially shows apparent absence of

Arch aortogram initially shows apparent absence of left vertebral artery opacification. With delayed imaging on the same patient (right image), the left vertebral artery fills retrogradely to supply the left subclavian artery, confirming left subclavian steal phenomenon secondary to a severe stenosis of the proximal left subclavian artery.

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Gadolinium-enhanced magnetic resonance angiography

Gadolinium-enhanced magnetic resonance angiography maximum intensity projection image shows left subclavian artery occlusion in a patient with left subclavian steal phenomenon and aberrant right subclavian artery. The patient had no neurologic or arm symptoms, but the subclavian lesion eliminated the left internal mammary artery as a coronary bypass graft option.

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Most commonly, subclavian artery steno-occlusive disease is not associated with symptoms and therefore can be managed conservatively with attention to diabetes and hyperlipidemia management, cessation of smoking, and antiplatelet therapy. When symptomatic, coincident significant carotid system stenoses should be excluded. Endovascular treatment is considered the first-line intervention in medically refractory patients with symptomatic subclavian steal syndrome. Surgical options, such as carotid-subclavian bypass, are generally reserved for patients in whom endovascular treatment has failed.

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