Treatment of subclavian artery stenosis: A case series

Abstract

Introduction: In this case series, different modalities of treatment for patients with ischaemic symptoms of subclavian stenosis are described, including the different operative strategies that can be adopted in more challenging cases. This is the first case series describing these four management options.

Presentation: Case 1: A seventy-one year-old female presented with acute on chronic ischaemia of her left arm following a fall and developed dry gangrene of her left thumb. This was initially managed with a heparin infusion followed by stenting of the subclavian artery which relieved her symptoms. Case 2: A fifty-nine year-old male presented with chronic ischemia of the left arm secondary to an occlusion of the left subclavian artery. This was managed by transposition of the left subclavian artery onto the left common carotid artery. Case 3: A sixty-four year-old female presented with left subclavian steal syndrome secondary to subclavian artery stenosis. She underwent carotid subclavian artery bypass. Case 4: A fifty-six year-old female presented with acute left upper limb ischaemia secondary to acutely thrombosed subclavian artery on a CT-angiography. She underwent a carotid to axillary bypass.

Discussion and conclusion: This case series demonstrates the treatment options available to vascular surgeons when managing symptomatic subclavian artery disease. Symptomatic subclavian artery occlusive disease should be treated with endovascular stenting and angioplasty as first line management. If it is not successful then open surgery should be considered. Bypassing the carotid to the subclavian or to the axillary artery are both good treatment modalities.

Keywords: Subclavian artery stenosis; Subclavian steal syndrome.

Fig. 1

(a) Pre-op MRA showing subclavian artery stenosis. (b) Post stent insertion.

Fig. 2

(a) Pre-operative MRA showing an occlusion of the proximal left subclavian artery extending to the origin of the left vertebral artery. (b) MRA after transposition of the left subclavian artery to the left common carotid artery.

Fig. 3

(a) Intraoperative dissection during carotid-subclavian bypass. (b) Intraoperative image showing PTFE graft in situ between left carotid and axillary arteries.

Fig. 4

Intraoperative image for carotid-axillary bypass.