Dialysis arteriovenous fistula causing subclavian steal syndrome in the absence of subclavian artery stenosis

Abstract

We present a rare cause of subclavian steal syndrome secondary to a dialysis arteriovenous fistula (AVF). A 69-year-old female with end-stage renal disease presented with ataxia and recurrent fainting spells. Angiography revealed normal subclavian arteries bilaterally, a right VA origin occlusion, and an apparent left VA origin occlusion. However, carotid artery angiography demonstrated flow through the posterior communicating artery with retrograde filling of the basilar artery and left VA to its subclavian origin. Repeat left subclavian arteriography during external compression of the AVF demonstrated normal antegrade left VA flow. The AVF was subsequently ligated resulting in complete symptom resolution.

Figure 1

(a) Lateral right subclavian artery angiogram (cranial view) demonstrating occlusion of the right VA with distal reconstitution (1) through muscular branches of the right ascending cervical artery (2). (b) Left subclavian artery angiogram demonstrating normal subclavian artery caliber and a stump at the left vertebral origin with no antegrade VA flow. (c and d) Anteroposterior right common carotid angiogram (cranial and cervical views, resp.) demonstrating flow through the p-comm. artery with retrograde filling of the basilar and left VA down to the level of the subclavian artery.

Figure 2

(a) Aortic arch angiogram demonstrating the overall hemodynamics. There is occlusion of the right VA origin and antegrade flow through the right common carotid artery (1) with reversal of flow in the left VA (2) down to the left subclavian artery (3). Note the early antegrade flow through the left subclavian artery (3) and the early filling of the left subclavian vein (4) indicative of the high flow through the dialysis AVF. (b) Anteroposterior left subclavian angiogram with occlusion of the AVF shows reestablishment of normal antegrade flow through the left vertebral artery.