Diagnosis of subclavian steal in infants with coarctation of the aorta and interruption of the aortic arch by color-coded Doppler sonography

We report the noninvasive diagnosis of subclavian steal by color-coded Doppler ultrasonography in nine infants with congenital heart disease. The underlying cardiovascular malformations included coarctation of the aorta in four infants, interrupted aortic arch type B in three patients, truncus arteriosus communis type A4 (one patient), and isolation of the right subclavian artery (one patient). In all patients both vertebral arteries could be displayed through the anterior fontanel in coronal sections. Normally the flow in both vertebral arteries, as well as the flow in the basilar artery, is displayed in red. In eight patients with angiographically proved unilateral subclavian steal, an antegrade (red) flow could be shown in one vertebral artery, whereas the contralateral vertebral artery was displayed blue, indicating reverse flow. In one infant with interrupted aortic arch type B and associated aberrant right subclavian artery, both vertebral arteries and the basilar artery were displayed blue, indicating bilateral subclavian steal. Color-coded Doppler sonography seems to be a sensitive, noninvasive method for diagnosing congenital subclavian steal, especially in infants with obstruction of the aortic arch.     

Physiological determinants of quality of life

A young man was found shivering and incoherent at home. He was placed in bed and was observed having seizures some time later. About four hours after he was initially found, he suffered a full cardiac arrest. Paramedics found his jaw unusually stiff and were unable to open his mouth in order to intubate him. Resuscitation attempts were unsuccessful. The autopsy findings were unremarkable, but toxicology testing revealed the following: moclobemide (subclavian blood, 18.5 mg/L; liver, 28.5 mg/kg; gastric contents, 77 mg/69 g) and paroxetine (subclavian blood, 1.58 mg/L; liver, 15.3 mg/kg; gastric contents, 0.7 mg/69 g). The cause of death was attributed to the combined toxicity of moclobemide and paroxetine. Deaths attributed primarily to these drugs are extremely rare because both are considerably less toxic than older monoamine oxidase and tricyclic antidepressant drugs. Based on the history of the case and pharmacology of the drugs involved, the most likely mechanism of death was severe "serotonin syndrome" resulting from the overdose.     

Right eye blindness as the predominating clinical sign in a patient with aortic arch syndrome: a case report

A case is described of pulseless disease in 43 years old man with right-sided blindness as the main clinical sign. The brain was supplied with blood via the left vertebral artery. The cerebral circulation was additionally diminished by coexisting subclavian steal-syndrome with reversal of blood flow in the right vertebral artery.     

Fallibility of persistent blood return for confirmation of intravascular catheter placement in patients with hemorrhagic thoracic effusions

Two patients are described with hemorrhagic thoracic effusions who required central venous catheterization. Presumed subclavian and internal jugular vein cannulation, ipsilateral to the hemorrhagic thoracic effusions, was confirmed by the operators in each case by the persistent aspiration of blood. Subsequent clinical and radiologic evaluation revealed that the vascular catheters were introduced into the pleural space. In both individuals, the persistent aspiration of extravascular hemorrhagic fluid mimicked intravascular catheter positioning. Physicians treating patients with hemorrhagic thoracic effusions need to be aware of this potential complication that can result in the delayed resuscitation of hemodynamically unstable patients.     

Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study

BACKGROUND: Catheterization of the subclavian vein may lead to severe complications. The current randomized study compared a technique of pulsed Doppler ultrasonography guidance and the standard method for subclavian vein catheterization. METHODS: Standard and Doppler ultrasonography guidance methods were performed by the same physician in 286 patients, 143 in each group. Primary end points were immediate complications (arterial puncture, pneumothorax, wrong position of catheter tip), failures, the number of subclavian vein catheterizations with immediate complication or failure, the number of skin punctures per catheterization, and the time to placement of the guide wire. The secondary end points were the determination of predicting factors of successful cannulation in each group. RESULTS: Both groups were similar according to morphologic parameters of the patients. A greater number of subclavian vein catheterizations were performed on the right side using Doppler guidance (105 vs. 73, P < 0.01). Doppler guidance decreased complications (5.6% vs. 16.8%, P < 0.01), largely because of a smaller number of catheters for which the tip was defined to be in incorrect position (0.7% vs. 7.7%, P < 0.01). The time to catheterization was longer with Doppler guidance (300 vs. 27 s, P < 0.001). Failures, catheterizations of the subclavian vein with immediate complications or failure, and the total number of skin punctures per catheterization were similar in both groups. Using Doppler guidance, the presence of a good Doppler signal (124 of 143) was predictive of successful catheterization (123 successful cannulations, P < 0.001). CONCLUSIONS: Doppler guidance reduces the incidence of inappropriately positioned subclavian catheters.     

Massive pulmonary hemorrhage in a patient treated with a platelet glycoprotein IIb/IIIa inhibitor

The authors describe an association of atrial septal defect with partial symptoms of the Poland-Moebius syndrome. Both are thought to be caused by developmental disorders of the mesenchyme and ectodermal derivatives. This anomalous association can be accepted as one concept of the subclavian artery blood supply disruption sequence during embryo-genesis.     

Aneurysms of the subclavian artery in thoracic outlet syndrome

The true subclavian artery aneurysm is a rare but dangerous complication of TOS. During a 20 years time period we observed 18 patients with subclavian artery aneurysms. 12 of these patients showed cervical ribs. Half of the patients (n = 9) presented with a critical ischemia of an upper extremity, nine patients were operated on electively. The acute ischemia makes the desobliteration of the outflow tract necessary first. The next step ist the transaxillary exarticulation of the first rib and the resection of the aneurysm. The reconstruction of the subclavian artery is performed by using autologous vein material or PTFE prostheses. In two cases both with an acute embolic critical ischemia major amputations were unavoidable. 13 patients could be reexamined in 1996: 11 bypasses proved to be functioning, 2 were definitely occluded.     

Surgery for coarctation of the aorta in infants younger than 3 months: end-to-end repair versus subclavian flap angioplasty: is either operation better?

OBJECTIVE: Recurrent coarctation is a complication which is seen at a consistent rate following all types of repair for coarctation of the aorta. Particularly disappointing late results are reported in younger infants, under 3 months of age. This retrospective analysis was undertaken to compare the outcomes on late follow-up between subclavian flap angioplasty and resection and end-to-end repair, in this age group. METHODS: Over a 12-year period, between 1982 and 1994, 86 infants under 3 months of age underwent surgical repair of coarctation (39 resections and end-to-end repair, and 47 subclavian flap angioplasty procedures). Operative mortality was not significantly different (P = 0.6) between resection and end-to-end repair (5.1%) and subclavian flap angioplasty (8.5%). All operative deaths (six patients) were in infants with associated ventricular septal defects. The mean follow-up for all patients was 7.95 years +/- 4.10 (range 0-14.5 years). The 5-year survival for resection and end-to-end repair was 87 +/- 5%, compared to 75 +/- 7% for subclavian flap angioplasty (P = 0.2). RESULTS: Recurrent coarctation occurred in nine patients who needed reoperation. The reoperation-free rates at both 5 and 10 years for resection and end-to-end anastomosis, and subclavian flap repair were 86 +/- 6% and 90 +/- 5%, respectively. The recurrence in the resection and end-to-end anastomosis group were due to constrictive scarring at the anastomosis, whereas periductal tissue and growth of posterior aortic ridge caused recurrence in the subclavian flap angioplasty group. There were no deaths during reoperation for recurrence. CONCLUSIONS: Both procedures are extremely effective for coarctation repair in young infants and run a similar risk of recurrence, which are due to completely different mechanisms. The surgeon's expertise is the major determinant of outcome.     

Surgical treatment of atherosclerotic lesions of subclavian artery: carotid-subclavian bypass versus subclavian-carotid transposition

BACKGROUND: The aim of this retrospective study is to analyze the short and long term results of two different surgical treatments in patients with subclavian lesions: common carotid-subclavian artery bypass (CSB) versus transposition of subclavian artery on the common carotid artery (SCT). METHODS: From 1981 until 1995, 40 non randomized patients with symptomatic subclavian steal underwent 20 CSBs and 20 SCTs. Risk factor rates were equally balanced in the two groups. Surgery was carried out routinely under general anesthesia, with electroencephalic continuous monitoring. Patency of revascularization was assessed by physical examination, brachial blood pressure determinations, ultrasound sonography and angiography whenever recurrence of symptoms developed or when the function of repair was in doubt. Patients were examined every year. In Spring 1996 (range 9-189 mos, average 7 years) a general clinical-instrumental follow-up was performed. RESULTS: In the short term (<30 days) mortality was 5%: one death (5%) for pulmonary embolism in a patient with CSB and one for myocardial infarction in a patient with SCT. The early thrombosis rate was 5% (1 CSB and 1 common carotid artery distal to a patent SCT). During follow-up 10 patients (25%) died and 6 were lost. The six-year actuarial patency rate was 100% for SCT and 66% for CSB. Moreover there were 3 thromboses of the vertebral artery homolateral to patent CSBs. CONCLUSIONS: In conclusions SCT should be considered the surgical technical choice for the treatment of proximal subclavian artery lesions.     

Iatrogenic vertebrobasilar insufficiency after surgery of the subclavian or brachial artery: review of three cases

OBJECTIVE AND IMPORTANCE: Vertebrobasilar insufficiency resulting from disease of the subclavian artery is well recognized. Usually, this occurs as the "subclavian steal" syndrome in the context of chronic subclavian stenosis and is consequently well tolerated because of collateralization. Acute disruption of the hemodynamics of the aortic arch vessels, however, can produce disastrous sequelae. CLINICAL PRESENTATION: We present three cases of iatrogenic vertebrobasilar insufficiency sustained as complications of surgery of the left subclavian artery or its distal continuation. The cases were chosen from a review of approximately 400 emergency neurosurgery consultations requested at the Los Angeles County Hospital between November 1995 and February 1996. INTERVENTION: The first patient underwent repair of a traumatic brachial artery occlusion and awoke postoperatively with bilateral cortical blindness, right hemiparesis, and multiple cranial nerve deficits that were most likely caused by acute subclavian steal. The second underwent removal of a subclavian embolus and developed bilateral cerebellar infarction leading to persistent coma, possibly from inadvertent embolization of the vertebral artery during surgery. The third underwent resection and bypass grafting of a subclavian aneurysm. Good backflow was reported when the vertebral artery was disarticulated from the subclavian artery, and this vessel was not reimplanted into the graft. The patient suffered massive cerebellar infarction leading rapidly to brain death. CONCLUSION: There are myriad ways in which the inherent redundancy of the vertebrobasilar system may be jeopardized, and when this protective mechanism fails, the results can be disastrous. Flow through the vertebral arteries may be compromised by thrombosis, embolization, dissection, inappropriate ligation, excessive head rotation, hypotension, vasospasm, or acute subclavian steal. These examples illustrate the importance of understanding the complex physiology of posterior fossa circulation as the basis of pre-, intra-, and postoperative management of patients undergoing surgery of the subclavian artery.     

A genome-wide scan for human obesity genes reveals a major susceptibility locus on chromosome 10

PURPOSE: To clarify the clinical feasibility of getting a long-term arterial access at the subclavian region by directly puncturing the artery under ultrasound guidance. MATERIALS AND METHODS: Percutaneous placements of arterial infusion catheters with implantable ports were performed in 30 patients with malignant abdominal tumors. The axillary artery in the subclavian region was punctured directly with an 18G needle under ultrasound guidance. Using the Seldinger technique, a 5Fr catheter was placed with its tip in the hepatic or the other tumor-supplying arteries. The catheter was connected to an implantable port, and both of them were embedded in the subcutaneous pocket. RESULTS: Percutaneous placements of infusion catheters were successfully performed in 29 cases. Transarterial chemotherapy through implanted ports was done uneventfully in 26 patients, while in the other three cases, catheter dislodgment occurred. Two local haematomas, one wound infection and one cerebellar infarction were also experienced. CONCLUSION: Ultrasound-guided subclavian approach is a minimally invasive way of implanting an infusion catheter for chemotherapy, although its indication for severely atherosclerotic patients should be limited.     

Aneurysms of the subclavian artery: clinical experience

The aneurysm of the subclavian artery is not common. The authors present three cases of aneurysms of the subclavian artery of which two cases already were in phase of complication for rupture. Two Patients underwent intervention of by-pass with Dacron prosthesis: between common carotid and axillary artery in one and between common carotid and distal head of the subclavian artery in the other. In a Patient with post-traumatic pseudoaneurysm of the subclavian artery was not possible to perform any intervention of direct reconstruction because of the precarious clinical conditions due to the hemorrhage for rupture and we performed only a resection of the aneurysm with binding of the subclavian artery. A Patient died two months after the operation for respiratory failure due to bronchial pneumonia; two Patients are still living, one with a moderate motor deficit of the upper limb. The rupture of the arteriosclerotic aneurysms of the subclavian artery is not frequent, but the gravity of this complication recommends the surgical treatment also in the asymptomatic cases if the clinical conditions of the Patient allow it.     

Protease-catalyzed synthesis of Leu-enkephalin in a solvent-free system

Percutaneous transluminal angioplasty (PTA) is a well-established treatment for patients with stenosis of limb arteries. However, its efficacy for treatment of severe stenosis and occlusions of the subclavian artery is unclear. We attempted to recanalize the subclavian artery in 30 patients with severe stenosis or total occlusion of proximal subclavian artery and successful outcomes were seen in 27 cases (90%). In two patients the regional arterial thrombolysis with the PTA prcedure we used was found successful. There was no severe complications. During an average 6-month follow-up stenosis recurred in 2 patients, but the subclavian artery was recanalized by repedted PTA.     

Bilateral subclavian steal: a review of an unusual twist in a common disorder

The authors present two cases of bilateral subclavian steal syndrome, a rare condition that does not commonly cause neurovascular symptoms. Lateralizing hemispheric events occur usually with carotid lesions. Vertebral-basilar insufficiency is three times more common in bilateral than in unilateral subclavian steal syndrome. Arm-exercise-induced brain-stem dysfunction is rare, and is seen only in bilateral subclavian steal syndrome.     

Risk of progressive sensorineural hearing loss and Meniere''s disease after breast implantation

Subclavian artery aneurysms are rare. They occur predominantly on the right side. The most frequent cause of proximal subclavian artery aneurysm is atherosclerosis. An aneurysm of the left subclavian artery with normal origin is less common, and it is extremely rare when associated with an aortic coarctation. This report describes the first case of bilateral subclavian artery aneurysms associated with a pseudocoarctation of the aorta. Successful resection of the left subclavian artery aneurysms and the pseudocoarctation of the aorta was achieved using partial cardiopulmonary bypass.     

Problem of catheter-embolism following subclavian puncture

The catheterisation into the subclavian vein is important in the intensive therapy and for the prolonged parenteral nutrition. Numerous complications are described. In 300 catheterisations into the subclavian vein we observed 3 damages of catheters. The causes damages of catheters are investigated with the help of experiments. Recommendations to the prevention of the damage and the embolism of the subclavian catheters are given.     

A case of persistent manic depressive illness induced by interferon-alfa in the treatment of chronic hepatitis C

Hemodialysis-associated subclavian venous stenosis should be suspected when upper extremity edema occurs after a graft or fistula has been placed there. Alternatively, venous thoracic outlet syndrome could also produce venous congestion, simulating subclavian stenosis. The latter diagnosis was unsuspected until central subclavian vein obstruction on venography became complete, with the arm passively hyperabducted. The patient's symptoms resolved after surgical decompression. Causes of thoracic outlet obstruction are reviewed.     

Prospective study of thromboses of the subclavian vein after setting implantable venous access systems in cervico-facial cancerology

Seventy-eight consecutive patients treated by chemotherapy for ENT cancers and having a subclavian catheter for venous access were studied prospectively to assess the prevalence of venous thrombosis. Thrombosis of the subclavian vein was demonstrated clinically in 4 patients and by ultrasonography in 7 patients. The prevalence of thrombosis was 14.1%. No clinical or biological predisposition factor could be identified. Subclavian thrombosis mostly occurred during the second month after implantation (91% of cases). Ultrasonography seems the most useful non-invasive technique for the diagnosis of subclavian thrombosis.     

A new minimally invasive approach to the subclavian artery

Aneurysms of the subclavian artery are rare. We report a case in which an aneurysm of the right subclavian artery presented as localized atrophy of the deltoid muscle. Operative repair was accomplished by a new minimally invasive surgical approach.     

Haemothorax after subclavian vein cannulation

A patient in whom pulmonary arterial bleeding occurred during percutaneous supraclavicular puncture of the subclavian vein is described. A retrospective survey of over 600 subclavian venepunctures disclosed seven patients in whom serious traumatic complications occurred, six of them in the hands of inexperienced operators.