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Subclavian and brachiocephalic artery stenosis

Background

Overview

Definition
Subclavian and brachiocephalic artery stenosis refers to the narrowing of these arteries, typically due to atherosclerosis or arterial dissection.
1
Pathophysiology
Subclavian and brachiocephalic artery stenosis can lead to decreased blood flow and impaired oxygen delivery to the upper extremities and brain.
1
Epidemiology
The epidemiology of subclavian and brachiocephalic artery stenosis is not well-defined due to their relative rarity, and prevalence and incidence rates are not explicitly reported.
1
Disease course
Clinical manifestations include symptoms of lightheadedness, syncope, left-sided weakness, subclavian steal syndrome, and arm claudication.
1
Prognosis and risk of recurrence
The prognosis can be severe if left untreated. Subclavian stenosis is associated with increased total and CVD mortality, even after adjustments for CVD risk factors and existent CVD at baseline.
2

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of subclavian and brachiocephalic artery stenosis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC/ESVS 2018) and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011). ...
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Screening and diagnosis

Indications for screening
As per ESC/ESVS 2018 guidelines:
Screen for PAD of lower and upper extremities in patients undergoing TAVI or other structural interventions requiring an arterial approach.
B
Obtain full vascular assessment in all patients being candidates for heart transplantation or cardiac assist device implantation.
B
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Diagnostic investigations

Diagnostic imaging: as per AANN/AANS/ACC/ACR/AHA/ASA/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS 2011 guidelines, obtain CTA or MRA for detection of vertebral artery disease as part of the initial evaluation of patients with subclavian steal syndrome.
B

Medical management

Management of hypertension
As per ESC/ESVS 2018 guidelines:
Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension.
A
Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension.
C

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  • Management of dyslipidemia

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Nonpharmacologic interventions

Lifestyle modifications: as per ESC/ESVS 2018 guidelines, advise smoking cessation,
B
healthy diet and physical activity in all patients with PADs.
B

Therapeutic procedures

Indications for revascularization: as per ESC/ESVS 2018 guidelines, consider performing revascularization in symptomatic patients with subclavian artery stenosis/occlusion.
C
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  • Endovascular revascularization

Surgical interventions

Surgical revascularization: as per AANN/AANS/ACC/ACR/AHA/ASA/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS 2011 guidelines, consider performing revascularization by direct arterial reconstruction or extra-anatomic bypass surgery in patients with symptomatic ischemia involving the anterior cerebral circulation caused by common carotid or brachiocephalic artery occlusive disease.
C
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Quality improvement

Hospital requirements: as per ESC/ESVS 2018 guidelines, healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.
B