Optimal interventional treatment in a patient with occlusion of the brachiocephalic trunk and left subclavian artery with “double” steal syndrome

Introduction

Subclavian steal syndrome, which comprises reversal of flow in the ipsilateral vertebral artery with stenosis or occlusion of the subclavian artery (SA) or brachiocephalic trunk (BCT), was first described by Contorni in 1960 [1]. This clinical syndrome manifests with the signs and symptoms of vertebrobasilar insufficiency, but can also be asymptomatic.
This paper describes a step-by-step technique of complex endovascular treatment for a double steal syndrome caused by occlusions of the BCT and the left SA, associated with stenosis of the left internal carotid artery (ICA) and reversed flow in the left external carotid artery (ECA).

Case report

A 64-year-old man with a 3-month history of non-specific neurological symptoms, such as vertigo and syncope, was admitted to our hospital. He presented with cardiovascular risk factors: grade 3 hypertension and hypercholesterolemia, and also with bilateral stenoses of the common iliac arteries. Doppler sonography revealed occlusions of the BCT and of the left SA, and stenosis of the left ICA caused by a long atherosclerotic plaque, with increased systolic and diastolic flow velocities to 350 cm/s and 120 cm/s, respectively. In the past, in another medical centre, he underwent an unsuccessful attempt of endovascular revascularization of the left SA.
After a thorough diagnostic evaluation, including assessment of the patient’s neurological status and the above-mentioned sonographic examination, we decided to perform catheter angiography of the arteries supplying the brain, in order to obtain more information about cerebral hemodynamics. This examination revealed occlusion of the BCT localized about 1 cm from the aorta, occlusion of the left SA localized about 2 cm from the aorta, and also an 80–90% stenosis of the left ICA (Figures 1 A–C). Morphology of these lesions was typical of atherosclerosis and not of fibromuscular dysplasia or Takayasu disease. Moreover, a detailed analysis of angiographic pictures revealed the presence of a double steal syndrome. First, there was reversed flow via collateral from the left ECA to the left SA, and then to the left vertebral artery (VA) and the basilar artery. This collateral network constituted the main blood supply to the posterior part of the brain, since there was no inflow of injected contrast from the left carotid artery through the Willis circle to the basilar and cerebellar arteries (Figures 1 D, E).
Taking into...


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