From the Guidelines
Vascular steal syndrome is diagnosed based on symptoms of posterior cerebral circulatory insufficiency aggravated by upper-limb exercise, and management options include subclavian revascularization with endovascular or surgical techniques for symptomatic patients. The diagnostic criteria for vascular steal syndrome include symptoms such as lightheadedness, syncope, vertigo, ataxia, diplopia, and motor deficits, which occur due to retrograde flow in the ipsilateral vertebral artery during upper-extremity exertion 1.
Diagnostic Criteria
The diagnosis of subclavian steal syndrome should be considered in patients with:
- Symptoms of posterior cerebral circulatory insufficiency aggravated by upper-limb exercise
- Asymmetry between left and right arm blood pressure measurements
- Detection of a periclavicular or infraclavicular bruit
- Reversal of flow in a vertebral artery on duplex ultrasonography
- Stenosis of the subclavian artery on CTA or MRA of the aortic arch
Management Options
Management options for vascular steal syndrome include:
- Conservative measures for asymptomatic patients, such as strategies directed at the secondary prevention of ischemic events related to systemic atherosclerosis
- Subclavian revascularization with endovascular or surgical techniques for symptomatic patients
- Consideration of the ipsilateral internal mammary artery requirement for myocardial revascularization in patients with subclavian steal syndrome 1.
Important Considerations
It is essential to note that involvement of the brachiocephalic or common carotid artery can lead to symptomatic cerebral hypoperfusion, and the coronary ischemic form of subclavian steal syndrome can produce angina pectoris during arm exercise 1.
From the Research
Diagnostic Criteria for Vascular Steal Syndrome
- Clinical features such as rest pain and ischemic ulcers in the fingertips are indicative of vascular steal syndrome 2
- Non-invasive studies, including duplex imaging and Doppler pressure assessment, can be used to evaluate the hemodynamics of the arteriovenous fistula (AVF) and diagnose steal syndrome 2, 3
- Angiography may be necessary to find out the real causes of the steal syndrome and to diagnose arterial stenoses 3, 4
- A flat waveform on photoplethysmography that converts to a pulsatile waveform when the proximal graft is compressed is also indicative of vascular steal syndrome 5
Management Options for Vascular Steal Syndrome
- Flow reducing procedures, such as surgically created stenosis or banding of the AVF, can be used to decrease flow in the AVF and increase flow to the hand 2, 5
- Distal revascularization interval ligation (DRIL) method can be used to treat steal syndrome by increasing blood flow to the distal extremity 4, 6
- Percutaneous transluminal balloon angioplasty (PTA) can be used to treat arterial stenoses that are contributing to steal syndrome 3
- Access ligation or revision may be necessary in some cases to treat steal syndrome 3, 6
- Consideration should be given to construction of access using smaller forearm arteries and looped AVG configuration in patients with high risk for steal 6
Factors Associated with Vascular Steal Syndrome
- Atherosclerotic burden, including coronary artery disease and peripheral arterial disease, is associated with an increased risk of developing steal syndrome 6
- The use of brachial artery inflow and straight AVG configuration is also associated with an increased risk of developing steal syndrome 6
- Diabetes may be a risk factor for developing vascular steal syndrome 5