Management and Treatment for Steal Syndrome Syncope
Direct corrective angioplasty or surgery is the treatment of choice for steal syndrome syncope, as it effectively addresses the underlying vascular obstruction and restores normal cerebral blood flow. 1
Understanding Steal Syndrome
Steal syndrome occurs when blood flow is rerouted away from the brain due to arterial stenosis or occlusion, most commonly affecting the subclavian artery. This condition is characterized by:
- Retrograde flow in the ipsilateral vertebral artery, especially during upper arm exercise, resulting in diminished cerebral blood flow 1
- Symptoms typically triggered by physical exertion of the affected arm 1
- Manifestations including syncope, vertigo, lightheadedness, ataxia, and motor deficits due to posterior cerebral circulatory insufficiency 1
Pathophysiology
- Subclavian steal syndrome occurs when low pressure within the subclavian artery causes retrograde flow in the ipsilateral vertebral artery 1
- The condition may be congenital or acquired, with atherosclerosis being the most common cause 1
- When the dominant vertebral artery is affected, basilar artery perfusion may be reduced, leading to posterior cerebrovascular insufficiency 1
Diagnostic Approach
Proper diagnosis is essential before initiating treatment:
- Blood pressure measurement in both arms - asymmetry suggests subclavian artery stenosis or occlusion 1
- Auscultation for periclavicular or infraclavicular bruits 1
- Duplex ultrasonography to identify reversal of flow in a vertebral artery 1
- CTA or MRA of the aortic arch to identify stenosis of the subclavian artery 1
- Comprehensive arteriography to evaluate the extent of arterial stenosis and delineate anatomy 2
Treatment Options
Endovascular Intervention
- Balloon angioplasty and stenting are effective first-line treatments with high success rates 1
- Initial success rates approach 93-98% for endovascular procedures 1
- Stenting shows better outcomes than angioplasty alone 1
- Patency rates after endovascular therapy: 93% at 1 year and 70% at 5 years 1
Surgical Revascularization
- Surgical options include:
- Surgical repair shows excellent results with:
Treatment Selection
- For symptomatic patients, revascularization (either endovascular or surgical) should be considered 1
- Asymptomatic patients with subclavian steal generally require no specific intervention beyond standard secondary prevention strategies for atherosclerosis 1
- Exception: asymptomatic patients may require intervention if the ipsilateral internal mammary artery is needed for myocardial revascularization 1
Special Considerations
- Coronary-subclavian steal syndrome may occur in patients with prior CABG using the internal mammary artery, presenting with chest pain and syncope during arm exercise 3
- When steal syndrome coexists with carotid disease, carotid endarterectomy should be performed first, as this may resolve all symptoms 4
- Comprehensive imaging of the arterial circulation is recommended to properly assess arterial anatomy and develop an appropriate treatment strategy 2
Treatment Outcomes
- Following appropriate intervention, most patients become symptom-free 5, 2
- Surgical approaches demonstrate excellent long-term results with low operative risk 4
- Endovascular stenting can successfully treat subclavian steal syndrome using modern equipment and techniques 5