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Subclavian Steal Syndrome

Nidhi Shankar Kikkeri; Shivaraj Nagalli.

Author Information and Affiliations

Last Update: July 3, 2023.

Continuing Education Activity

Subclavian steal syndrome (SSS), now termed subclavian-vertebral artery steal
syndrome, refers to the diversion of blood flow away from its normal target and
the arm. It is a cause of syncope or presyncope related to cerebral hypoperfusion
that occurs during arm use. This condition commonly results from arteriovenous
malformations that are either congenital or iatrogenic. A coronary variant of
subclavian-vertebral artery steal syndrome can occur as an adverse effect of
coronary artery bypass when using the arm on the same side of the internal
mammary artery graft used to bypass the narrowed or obstructed coronary
vessel. This variant usually results in symptoms of cardiac ischemia such as
angina or, in severe cases, can cause myocardial infarction. The defining feature
of subclavian-vertebral artery steal syndrome is the pathophysiologic
phenomenon of taking blood flow away from the vertebrobasilar or coronary
circulation and diverted to the arm. This activity illustrates the evaluation and
treatment of subclavian-vertebral artery steal syndrome and reviews the role of
interprofessional team members in managing those with this condition.

Objectives:

Outline the differential diagnosis of subclavian-vertebral artery steal

syndrome.

Describe the evaluation of subclavian-vertebral artery steal syndrome.

Explain how to properly manage a patient affected by the subclavian-

vertebral artery steal syndrome.

Review the role of interprofessional team members in optimizing

collaboration and communication to ensure high-quality care for patients
with subclavian-vertebral artery steal syndrome, thereby leading to
enhanced outcomes.

Access free multiple choice questions on this topic.

Introduction
Subclavian steal syndrome (SSS), also known as subclavian-vertebral artery steal
syndrome, is a phenomenon causing retrograde flow in an ipsilateral vertebral
artery due to stenosis or occlusion of the subclavian artery, proximal to the origin
of the vertebral artery. [1] Subclavian steal is asymptomatic in most patients and
does not warrant invasive evaluation or treatment. It can manifest in some
patients with symptoms of arterial insufficiency affecting the brain or the upper
extremity, supplied by the subclavian artery.

Etiology
The most common etiology of subclavian steal syndrome is atherosclerosis.
Subclavian steal syndrome is more commonly seen on the left side, possibly due
to the more acute origin of the left subclavian artery, leading to increased
turbulence, causing accelerated atherosclerosis [2].

Some of the other risk factors for SSS include[3][4][5]:

Takayasu arteritis, which is a form of large vessel granulomatous vasculitis,

commonly seen in young or middle-aged women of Asian descent

Subclavian artery compression in the thoracic outlet. This presentation

usually presents in athletes like cricket bowlers and baseball pitchers, due to
neuromuscular compression, as the subclavian artery crosses over the first
rib.

Presence of cervical rib, which is an extra rib that originates from the
seventh cervical vertebra

Following surgical repair of coarctation of the aorta

Congenital abnormalities like right aortic arch

Rare anatomical factors include aortic dissection, vertebral artery

congenital malformations, and even external vertebral artery compression

Epidemiology
The exact incidence or prevalence of subclavian steal syndrome is not known.
Most literature reports the prevalence of SSS as between 0.6% to 6.4%.[6] The
Joint Study of Extracranial Arterial Occlusion by Fields et al., showed a 2.5%
incidence (168/6534), with only 5.3% of these patients experiencing neurological
symptoms.[7] Males are more affected compared to females, due to
atherosclerotic causes, by a ratio of about 2 to 1.

Pathophysiology
The pathophysiology involves blood flow diversion from the brain territories to
the arm, causing symptoms of vertebrobasilar insufficiency, especially during the
vigorous exercise of the arm or sudden sharp turning of the head in the direction
of the affected side. The symptoms arise due to two types of mechanisms by
which the arm "steals" blood flow from the vertebrobasilar territory; 1) a lack of
blood supply because of subclavian artery stenosis or 2) rarely malformation
disease, that may include an arteriovenous distal arm shunt.

The severity of subclavian steal is classified into three grades[8]:

Grade I (pre-subclavian steal) - reduced antegrade vertebral flow.

 Grade II (intermittent/partial) - alternating flow - antegrade flow in the
diastolic phase and retrograde flow in the systolic phase.

Grade III (permanent/advanced) - permanent retrograde vertebral flow.

Coronary subclavian steal syndrome is another type of subclavian steal

syndrome, described in patients who have undergone coronary artery bypass
graft surgery using internal mammary artery (IMA) graft.[6] It is defined as the
reversal of flow in a previously constructed IMA leading to myocardial ischemia,
due to the presence of subclavian artery stenosis, proximal to the origin of the
ipsilateral IMA.

History and Physical

Subclavian artery stenosis is asymptomatic in most patients. It is sometimes
incidentally found when there is a blood pressure difference between the arms or
on ultrasound testing of patients with coronary or carotid artery disease.

It can be symptomatic in some patients and can present as arm pain, fatigue,
numbness, or paresthesias. These symptoms are secondary to upper
extremity ischemia during vigorous exercise.

It can also present as a variety of neurological symptoms secondary to

vertebrobasilar insufficiency. These symptoms include dizziness, blurring of
vision, syncope, vertigo, disequilibrium, ataxia, tinnitus, or hearing loss. The
neurological symptoms can be precipitated by upper extremity exercise as
well as with head movements, with the rotation of face toward the opposite
side. A detailed history can help in diagnosing subclavian steal.

On examination, a difference of at least 15 mmHg presents between the

affected and the normal arm.

Simultaneous palpation of radial pulses in both arms will show a decreased

amplitude and delayed arrival on the affected side.

Examination of bilateral carotid arteries using palpation and auscultation

can also help in detecting occlusive disease.

Subclavian arteries should be examined in the supraclavicular fossa using

palpation and auscultation for paraclavicular bruits.

Evaluation
Duplex ultrasound is one of the less invasive bedside investigations to start with if
the symptoms are consistent with subclavian steal syndrome, and it is always
indicated as the first-line of tests. It can readily diagnose and also quantify
proximal subclavian artery stenoses. Significant subclavian artery stenosis is
predicted by a subclavian artery peak systolic velocity greater than 240
cm/second.[9] However, a Doppler ultrasound cannot properly evaluate the origin
of the vertebral artery. It helps in identifying the extracranial occlusive disease.

Magnetic resonance angiography is an accurate diagnostic modality for patients

with suspected SSS.[10] It can also aid in the evaluation of intracranial
cerebrovascular circulation as well as the extracranial vessels.

CT angiography is another diagnostic modality that can help in the diagnosis and
grading of subclavian artery stenosis. It is indicated in patients with abnormal
findings on duplex ultrasound.

A confirmatory test is usually needed to decide on the intervention strategy, and

color doppler ultrasound must always be complemented with either contrast-
enhanced magnetic resonance angiography or computed tomography
angiography before making any decisions about treatment. Digital subtraction
angiography (DSA) is generally the choice if stenting has been decided as the
treatment of choice and helps better in depicting the details of the anatomical
hurdle.

Treatment / Management
Many patients do not require any intervention as either they are asymptomatic or
their mild and non-disabling symptoms improve with time.

Subclavian artery stenosis is a marker of atherosclerotic disease in many patients

and hence indicates the risk of adverse cardiovascular events in such patients.
These patients benefit from secondary preventive measures, including control of
blood pressure, treatment of dyslipidemia, smoking cessation, glycemic control in
diabetes mellitus, and lifestyle changes.

An open surgical bypass is one of the options for symptomatic patients. The most
common choice for surgical correction is extra-anatomic revascularization (e.g.,
carotid transposition, carotid-subclavian bypass).

For patients with short proximal stenosis or occlusion, an endovascular

intervention can be a consideration. About 10% of patients can present with less
than 70% recurrent stenosis. Such patients can benefit from repeat angioplasty.
About 5% of those patients might require surgery.[11]

Antiplatelet therapy and oral anticoagulation can be tried in patients with high
surgical risk or with unfavorable anatomy for surgical intervention. However, the
effectiveness of this option has not been studied.

Differential Diagnosis
Peripheral Arterial Disease (PAD) of the Upper Extremity

This can be secondary to thromboembolism, arteritis, or fibrodysplasia. It can

present with exercise-induced pain, pain at rest, or digit ulceration. Sometimes,
asymmetric arm blood pressures are the only finding. It can be differentiated
from SSS due to the absence of neurological manifestations in the former.

Posterior Circulation Stroke

This can present with neurological manifestations like syncope, dizziness,

blurring of vision, or ataxia. MR angiography or CT angiography can help in
differentiating it from subclavian steal syndrome.

Aortic Stenosis
In a patient presenting with syncope, though SSS merit considered in the
differentials, it is essential to rule out cardiac causes, including aortic stenosis. An
ejection systolic murmur in the aortic area on examination can be suggestive. An
echocardiogram is definitive in diagnosing aortic stenosis.

Diabetic Neuropathy

The presence of 'glove and stock' pattern of symptoms suggest peripheral

neuropathy. Electromyography may help in diagnosing peripheral neuropathy
and thereby distinguishing it from SSS.

Prognosis
Subclavian steal syndrome is a relatively benign condition. As it is a marker of
atherosclerosis, it can indicate the risk for future events like myocardial ischemia
or stroke. Hence, secondary preventive measures in patients can help in a good
prognosis. Symptomatic patients who undergo surgical intervention with
angioplasty and stenting or open surgical bypass, also have a good prognosis.
Most patients (over 95%) have sustained resolution of ischemic symptoms and do
not require reintervention of the target vessel.[11]

Complications
There are no long term complications reported from subclavian steal syndrome
by itself. But, as it can lead to vertebrobasilar insufficiency, patients who present
with syncope can experience falls, leading to the risk of head injury.

In coronary-subclavian steal, the reversal of blood flow through the internal

mammary graft from coronary to subclavian circulation can result in myocardial
ischemia.

Deterrence and Patient Education

Before treating the anatomical restriction to normal flow, it is vital to limit
exercising the extremity involved and prevent provoked episodes. Also, patients
with subclavian steal syndrome can benefit from secondary preventive measures,
including smoking cessation, glycemic control, BP control, and lifestyle changes.

Pearls and Other Issues

Subclavian steal syndrome should merit consideration as one of the

differentials in the evaluation of a patient with syncope.

Measurement of blood pressure in both arms showing marked differences

and thorough history taking and examination of the neck and chest is
essential in the initial evaluation of patients presenting with upper
extremity ischemic symptoms or neurological symptoms including syncope,
dizziness, ataxia, or vertigo.

Enhancing Healthcare Team Outcomes

An interprofessional approach with good communication between the primary
care physician, the neurologist, the radiologist, and the vascular surgeon is
essential to recognize and treat this condition. Patients have improved prognosis
with treatment.

Review Questions

Access free multiple choice questions on this topic.

Comment on this article.

References
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Disclosure: Nidhi Shankar Kikkeri declares no relevant financial relationships with ineligible
companies.
Disclosure: Shivaraj Nagalli declares no relevant financial relationships with ineligible
companies.

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