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Subclavian and brachiocephalic artery stenosis

Definition
Subclavian and brachiocephalic artery stenosis refers to the narrowing of these arteries, typically due to atherosclerosis or arterial dissection.
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Pathophysiology
Subclavian and brachiocephalic artery stenosis can lead to decreased blood flow and impaired oxygen delivery to the upper extremities and brain.
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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.
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Disease course
Clinical manifestations include symptoms of lightheadedness, syncope, left-sided weakness, subclavian steal syndrome, and arm claudication.
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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.
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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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Guidelines

1.Screening and diagnosis

Indications for screening
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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2.Diagnostic investigations

Diagnostic imaging: obtain CTA or MRA for detection of vertebral artery disease as part of the initial evaluation of patients with subclavian steal syndrome.
B

3.Medical management

Management of hypertension
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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4.Nonpharmacologic interventions

Lifestyle modifications: advise smoking cessation
B
, healthy diet and physical activity in all patients with PADs.
B

5.Therapeutic procedures

Indications for revascularization: consider performing revascularization in symptomatic patients with subclavian artery stenosis/occlusion.
C
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  • Endovascular revascularization

6.Surgical interventions

Surgical revascularization: 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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7.Quality improvement

Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.
B