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Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes., Competing Interests: Declaration of Competing Interest White None. Patel: Abiomed – speaker; LivaNova – speaker; Boston Scientific - speaker., (Copyright © 2021. Published by Elsevier Inc.)

Background: We investigated the mid-term results of carotid-axillary bypass (CAB) in the setting of zone II thoracic endovascular aortic repair as an alternative method for the left subclavian artery (LSA) revascularization., Methods: Our retrospective, single cohort study included all 69 patients from March 2015 to December 2018 with zone II thoracic endovascular aortic repair and CAB for the revascularization of the LSA. Demographics and clinical data were collected. We assessed several clinical outcomes: local complications (hematoma, injury of the brachial plexus, vagus and sympathetic chain nerve palsies, chyle leakage), subclavian steal, arm ischemia, paraplegia, mortality, and stroke. Follow-up computed tomography scans were analyzed for CAB and vertebral artery (VA) patency and the extent of thrombus formation in the LSA., Results: The in-hospital mortality was 3% and the perioperative stroke rate was 4%. Permanent paraplegia occurred in 3%. Perioperative morbidity included irritation of the brachial plexus (1%), sympathetic chain nerve palsy (1%), and wound hematoma in 3% of the cases. Phrenic and vagus nerve lesions and chyle leakage were not observed. Bypass patency was 97% at mean follow-up of 333 ± 39 days. VA occlusion was found in 6% of all cases. Strokes did not occur during the follow-up. Morbidity at follow-up included arm claudication (3%) in two patients with bypass thrombosis. Subclavian steal was observed in 3%. The LSA ostium was ligated (44%), plugged (22%), or left open (35%) in patients without a type II endoleak. Subgroup analysis of LSA thrombosis to the level of the VA was more prevalent after surgical ligature (P = .02), but had no negative effects on CAB or VA patency or stroke., Conclusions: CAB is a safe alternative to classic debranching procedures, with distinctive advantages regarding local complication rates described in the literature., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Antiplatelet therapy (APT) is often used on anecdotal grounds to improve vascular access patency. The aim of this study was to assess the role of APT in hemodialysis (HD) patients undergoing arteriovenous fistula (AVF) or graft (AVG) placement., Methods: All patients in a large HD vascular qualitative initiative database (2011-2017) were included and divided into no antiplatelet therapy (no-APT) vs. any APT [aspirin (ASA) or P2Y12 inhibitors (PI)]. Multivariate [logistic (MLR) and Cox (MCR) regression] analyses were used as appropriate., Results: A total of 24,847 patients undergoing HD access creation were identified (78% AVF). APT was noted among 49 and 46% of AVG and AVF patients, respectively. In MLR analysis, patients on no-APT vs. APT had a 12-fold increased risk of in-hospital mortality (odds ratio (OR) 11.79, [95% confidence interval 5.30-26.26]) and the risk of developing steal syndrome was higher among patients discharged on APT (OR 1.81, [1.19-2.76]). In patients undergoing AVF, primary patency (PP) was similar between APT and no-APT. However, in patients undergoing AVG, PP rates at 12 months were significantly higher for APT: ASA (47 vs. 41%) and PI (51 vs. 41%) than for no-APT (p = 0.008). At MCR analysis, the loss of PP at 12 months was 13% lower in ASA users (hazard ratio (HR) 0.87, [0.77-0.97], p = 0.02) and 24% lower in PI users (HR 0.76, [0.57-0.99], p = 0.046) compared to no-APT., Conclusion: In a large national database, we showed that antiplatelet therapy was associated with lower in-hospital mortality. Aspirin and P2Y12-inhibitor use among AVG patients demonstrated improved PP rates compared to no antiplatelet therapy. We recommend the use of antiplatelet therapy especially in patients on AVG.

To determine the risk of stroke in patients with subclavian steal syndrome (SSS). We identified 165 patients with imaging-provenSSS from two hospitals. Demographic, clinical and imaging data were retrospectively collected. Patients were followed up for stroke events. Stroke occurred in 43 patients with a median follow-up of 28months. Seven of these cases were identified prospectively and 36 cases retrospectively. On multivariate analysis, presence of symptoms at presentation (p=0.029) was a significant predictor of stroke. Presence of symptoms at presentation predicted stroke in imaging-proven SSS., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To identify independent predictors of cardiovascular events among patients with subclavian artery stenosis., Methods: Two hundred eighteen consecutive patients with subclavian artery stenosis referred to angioplasty were examined for coexistent coronary, renal, or lower extremity artery stenosis of 50% or greater. Initial carotid intima-media thickness and internal carotid artery (ICA) stenosis were assessed. Intima-media thickness was reassessed in 108 randomly chosen patients to evaluate the change over time. The incidence of cardiovascular death, myocardial infarction (MI), ischemic stroke, and symptomatic lesion progression was recorded., Results: The patients included 116 men and 102 women (mean age ± SD, 62.1 ± 8.4 years). Isolated subclavian artery stenosis and involvement of 1, 2, and 3 or 4 other territories with stenosis of 50% or greater were found in 46 (21.1%), 83 (38.1%), 55 (25.2%), and 34 (15.6%) patients, respectively. Internal carotid artery stenosis of 50% or greater (relative risk [RR], 1.54; 95% confidence interval [CI], 1.39-1.70; P < .001) and initial intima-media thickness (RR, 1.16; 95% CI, 1.05-1.28; P = .005) were identified as independent markers of multiterritory atherosclerosis. The optimal intima-media thickness cutoff for atherosclerosis extent was 1.3 mm (sensitivity, 75.6%; specificity, 76.1%). During follow-up of 57 ± 35 months, cardiovascular death, MI, and ischemic stroke occurred in 29 patients (13.3%). Those patients had significantly higher intima-media thickness progression (+0.199 ± 0.57 versus +0.008 ± 0.26 mm; P = .039) and more widespread initial atherosclerosis (mean territories, 1.8 ± 1.1 versus 1.3 ± 1.1; P = .042). Independent predictors of cardiovascular death, MI, ischemic stroke, and lesion progression were coronary artery disease (RR, 1.32; 95% CI, 1.10-1.58; P = .003) and intima-media thickness progression (RR, 1.22; 95% CI, 1.02-1.46; P = .033; sensitivity, 75.0%; specificity, 61.8%)., Conclusions: In patients with symptomatic subclavian artery stenosis, baseline carotid intima-media thickness and ICA stenosis of 50% or greater are associated with multiterritory atherosclerosis, whereas intima-media thickness progression is associated with the risk of cardiovascular events.

Background: Chronic, repetitive, and sublethal hypoperfusion by intra- or extracranial artery stenosis promotes collateral development and conditions the brain toward preventing subsequent lethal ischemia, although these latent properties have rarely been demonstrated in the clinical setting. This study assessed the previously unexplored role of subclavian steal syndrome (SSS) on inciting and protecting brain damage., Methods: We enrolled patients diagnosed with SSS associated with subclavian artery stenosis. Subclavian steal was determined by transcranial Doppler and/or digital subtraction angiography. We analyzed the prevalences and predictors of posterior ischemic symptoms and infarcts in SSS patients and also investigated individual cases to demonstrate a clinical evidence of brain conditioning, focusing on cytotoxic and vasogenic edema., Results: Of 54 SSS patients, 36 (66.7%) had been asymptomatic and incidentally diagnosed with SSS, whereas 18 (33.3%) patients had presented with posterior ischemic symptoms. Symptoms and infarcts including old silent lesions occurred more frequently as unstable hemodynamics of the anterior circulation were combined. Of 18 symptomatic patients, 13 patients (72.2%) had transient ischemic attack and 5 (27.8%) patients had an infarct in the posterior circulation territory. Four patients with cytotoxic edema had mild neurologic deficits and rapid and complete recovery, whereas 1 patient had prolonged, severe vasogenic edema after acute hypertension., Conclusions: Although we noted low rates of disabling or fatal strokes in patients with SSS, a variety of vascular and neural factors beyond severity of subclavian steal could influence the likelihood of brain damage., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Atherosclerotic subclavian artery stenosis (SAS) accompanied with other craniocervical artery stenosis (OCAS) is not uncommon in practice. We sought to investigate the safety and efficacy of endovascular stenting for SAS in patients with OCAS. Between January 2004 and February 2012, 71 consecutive atherosclerotic SAS patients who underwent primary stenting in our medical center were included. The enrolled patients were divided into combined-SAS group (n = 51) and solitary-SAS group (n = 20) depending on the presence or absence of OCAS. Data of demographics, procedure, and the followed-up were retrieved and analyzed. The technical success rate was 95.8%; the clinical success rate was 90.1%. There was no catheter-related major stroke or death. The immediate outcomes had no statistical difference between groups. During a mean of 27 ± 20 months (range 2-88 months) followed-up, 7 (10.3%) restenosis and 12 (17.6%) clinical events were identified. The primary patency rate was 95.3, 84.9 and 84.9% at 12, 24 months, and final followed-up respectively, which had no statistical difference between groups (odds ratio (OR), 2.60; 95% confidence interval (CI), 0.54-12.53; P = 0.232). The overall clinical event-free survival rate was 93.5, 86.2 and 54.6%, respectively, where the result of combined-SAS group was inferior to that of the solitary-SAS group (OR, 3.34; 95% CI, 1.02-11.00; P = 0.047). Endovascular stenting was safe and feasible for atherosclerotic SAS in patients with OCAS, although the combined OCAS may have a significant influence on the long-term outcome. Further studies are warrant to investigate the effects of revascularization for multiple craniocervical artery stenoses on the cerebral hemodynamics and long-term outcomes.

Steal syndrome is a feared complication of dialysis vascular access in a population becoming older and frailer. The aim of this study was to determine the predictor factors of steal syndrome. All proximal arteriovenous fistulas (AVFs), patent at day 30, inserted between January 2008 and December 2009 were studied. Data on age, gender, diabetes mellitus (DM) status, presence of coronary or peripheral artery disease, date of initiation of renal replacement therapy, date of access construction, localization, type of anastomosis, previous interventions, and outcome for AVF and patients were analyzed. There were 324 AVFs placed into 309 individual patients. The mean age was 66.7 ± 15.3 years, and the majority (53.7%) of the patients was male. Mean follow-up of all 324 fistulas was 18.6 ± 8.5 months. During follow-up, steal syndrome occurred in 26 (8%) of the AVFs. Univariate analysis revealed correlations between steal syndrome and DM (P = 0.002), brachiomedian fistulas (P = 0.016), and side-to-side (STS) anastomosis (P = 0.003). However, in multivariate analysis, the presence of DM, STS anastomosis, and female gender were found to be the independent risk factors. The strongest predictive factor was DM (odds ratio: 6.7; 95% confidence interval: 2.5-17.9). Being diabetic is the factor most predictive of having steal syndrome. In diabetic women, with a proximal access, it seems preferable to construct fistulas with end-to-side anastomosis to minimize the risk., (© 2012 The Authors. Hemodialysis International © 2012 International Society for Hemodialysis.)

Background: Data supporting epidemiological transition from a predominant burden of infectious diseases to one of chronic diseases in Africa result mostly from hospital surveys., Aim: To estimate the cardiovascular disease (CVD) burden in Gabon., Methods: The study was conducted in Ntoum (8765 inhabitants). All subjects aged greater or equal to 40 years were invited to participate. Participants were interviewed about CVD history and risk factors; they responded to questionnaires on claudication and angina and had a clinical examination, including lower limb pulse palpation and bilateral brachial pressure measurement. Subjects were considered to have CVD in case of history of CVD (coronary artery, cerebrovascular and peripheral arterial diseases), a positive questionnaire or an abnormal finding during clinical examination., Results: The study included 736 subjects (313 men; 423 women). Systolic hypertension was highly prevalent (up to 47.7% and 53.7% in men and women aged 50 to 60 years, respectively). Of the 382 patients with hypertension, 74 (19.4%) were treated and only 22 (5.8%) were considered to have controlled hypertension. Overall, CVD was identified in 98 (13.3%) cases. Overall and newly diagnosed CVD prevalence rates were 14.7% and 11.5% for men and 14.9% and 8.9% for women, respectively. The presence of CVD was associated with hypertension (hazard ratio [HR] 3.69, 95% confidence interval [CI] 2.21-6.16; P<0.0001). Hypertension was predictive of stroke (HR 4.57, 95% CI 1.26-16.50; P<0.05), peripheral artery disease (HR 2.03, 95% CI 1.03-4.00; P<0.05) and subclavian artery stenosis (HR 5.79, 95% CI 2.21-15.2; P<0.05)., Conclusions: Our findings provide strong evidence of ongoing epidemiological transition in Gabon, where CVD prevalence rates increase mainly with hypertension, affecting about one in six individuals aged over 40 years., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

An infant under follow-up evaluation since the fetal stage was detected to have subclavian steal syndrome (SSS) associated with heterotaxy syndrome and atrioventricular septal defect. Such a complex association has not been reported previously. Congenital SSS occurs as a result of a subclavian artery originating from the main pulmonary artery through the ductus instead of the aortic arch. In rare cases, as in the reported case, it may occur due to proximal segment atresia of the left subclavian artery.

Background: Recent studies indicate that subclavian stenosis (SS), diagnosed by a large systolic blood pressure difference (SBPD) between the right and left brachial arteries, is associated with cardiovascular disease (CVD) risk factors and outcomes. We sought to describe the epidemiology of SS and determine its association with markers of subclinical CVD in the baseline cohort of the Multi-Ethnic Study of Atherosclerosis., Methods: We defined SS by an absolute SBPD>or=15 mmHg. Peripheral artery disease (PAD) was defined by an ankle-brachial index100 vs. score=0; OR=1.43; 1.03-2.01)., Conclusions: The subclavian stenosis is positively associated with other markers of subclinical atherosclerosis., (Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the prevalence and impact of subclavian steal syndrome (SSS) in patients undergoing assessment of the carotid arteries., Summary Background Data: Vertebral artery flow reversal is often found among patients undergoing imaging of the extracranial vessels; however, there are no large studies evaluating the prevalence and natural history of SSS in stratified patients., Methods: Patients presenting for duplex ultrasound of the carotid arteries underwent 2 sets of bilateral arm pressure measurements. Patients with a pressure differential (PD) >20 mm Hg were examined in detail for vascular obstruction ipsilateral to the affected arm. When appropriate, computer tomographic angiography (CTA), magnetic resonance angiography, and angiography were performed. Signs and symptoms related to SSS and the types of interventions performed were recorded., Results: In a period of 6 years, 7881 carotid duplex scans were performed, with a PD >20 mm Hg in 514 (6.5%) patients and a left arm preponderance (82%). SSS was complete in 61%, partial in 23%, and absent in 16%. Symptoms were present in 38 patients with 32 experiencing symptoms of the posterior circulation, 4 of arm ischemia, and 2 of cardiac ischemia. Symptoms occurred more frequently as the arm PD increased. Of the 38 symptomatic patients, only 7 underwent an intervention (2 with subclavian-carotid bypass and 5 with percutaneous transluminal angioplasty stenting of the subclavian)., Conclusions: SSS is a frequent finding in patients undergoing carotid duplex scanning. Patients are commonly asymptomatic and rarely require an intervention. A significantly elevated arm PD (>40-50 mm Hg) is more commonly associated with symptoms, complete steal, and the need for intervention.

Background: We examined the prevalence of significant proximal left subclavian artery (LSA) stenosis in patients referred for isolated coronary artery bypass grafting, and assessed management by percutaneous transluminal angioplasty (PTA) for LSA stenosis and revascularization using the left internal thoracic artery, or revascularization using grafts other than the left internal thoracic artery., Methods: Between 1998 and 2007, significant proximal LSA stenosis was identified in 38 of 1,498 patients who underwent isolated coronary revascularization. Percutaneous transluminal angioplasty was performed before or after surgery in 20 patients (PTA group). Revascularization using grafts other than the left internal thoracic artery was performed in 18 patients with LSA stenosis unamenable to PTA (non-PTA group). Early, 1-year, and 5-year follow-up angiograms were performed to assess patency of both grafts and PTA. Computed tomographic angiography was also performed at 2 years in the PTA group., Results: Prevalence of significant LSA stenosis was 2.5%. Early, 1-year, and 5-year angiograms showed overall graft patency rates of 97.2% (105 of 108 distal anastomoses), 88% (81 of 92), and 92% (23 of 25), respectively. No differences were observed in graft patency rates between the two groups during the follow-up period. No intervention-related morbidities occurred in the PTA group. Estimated patency rates of PTA at 2 and 5 years were 100% and 85.7%, respectively., Conclusions: Percutaneous transluminal angioplasty for LSA and revascularization using the left internal thoracic artery may be an effective treatment for patients with significant LSA stenosis. In patients with LSA stenosis unamenable to PTA, revascularization using grafts other than the left internal thoracic artery may be another treatment option., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The subclavian steal effect indicates atherosclerotic disease of the supraaortic vessels but rarely causes cerebrovascular events in itself. Noninvasive imaging providing detailed anatomic as well as hemodynamic information would therefore be desirable. From a group of 25 consecutive patients referred for MR angiography, four with absent or highly attenuated signal in one of the vertebral arteries on 3D multislab time-of-flight MR angiography were selected to undergo 3D time-resolved contrast-enhanced MR angiography. The time-resolved 3D contrast series (source images and MIPs) were evaluated visually and by graphic analysis of time-intensity curves derived from the respective V1 and V3 segments of both vertebral arteries on the source images. In two cases with high-grade proximal left subclavian stenosis, time-resolved 3D ce-MRA was able to visualise retrograde contrast filling of the left VA. There was a marked delay in time-to-peak between the left and right V1 segments in one case and a shallower slope of enhancement in another. In the other two cases, there was complete or collateralised segmental occlusion of the VAs.

Background and Purpose: Early deterioration can occur after acute stroke for a variety of reasons. We describe a hemodynamic steal and associated neurological deterioration, the reversed Robin Hood syndrome (RRHS). We aimed to investigate the frequency and factors associated with RRHS., Methods: Consecutive patients with acute cerebral ischemia underwent serial National Institutes of Health Stroke Scale and bilateral transcranial Doppler monitoring with breathholding. Steal magnitude (%) was calculated from transient mean flow velocity reduction in the affected arteries at the time of velocity increase in normal vessels. Excessive sleepiness and likelihood of sleep apnea were evaluated by the Epworth Sleepiness Scale and Berlin Questionnaire., Results: Among 153 patients (age, 61+/-14 years; 48% women; 21% transient ischemic attack) admitted within 48 hours from symptom onset, 21 (14%) had steal phenomenon (median steal magnitude, 20%; interquartile range, 11%; range, 6% to 45%), and 11 (7%) had RRHS. RRHS was most frequent in patients with proximal arterial occlusions (17% versus 1%; P<0.001). The following factors were independently (P<0.05) associated with RRHS (multivariate logistic regression model): male gender, younger age, persisting arterial occlusions, and excessive sleepiness (P<0.001). A 1-point increase in the Epworth Sleepiness Scale was independently related to an increased likelihood of RRHS of 36% (95% CI, 7% to 73%)., Conclusions: RRHS and hemodynamic steal can be found in 7% and 14%, respectively, of consecutive patients with stroke without other known causes for deterioration. Patients with persisting arterial occlusions and excessive sleepiness can be particularly vulnerable to the steal.

Coarctation of the aorta is a cause of right arm hypertension in children and of heart failure in infants after ductal closure. We present two cases with these presentations that were initially thought to be coarctation of the aorta. They were subsequently diagnosed as Takayasu's arteritis in the older child and a large cerebral arteriovenous malformation in the infant. These conditions should be in the differential of right arm hypertension and of aortic flow reversal on echocardiography.

Percutaneous transluminal angioplasty (PTA) and stenting is commonly used to treat subclavian artery stenosis (SAS). In this study, the outcomes of 43 consecutive cases, performed at one institution from October 1997 to October 2005, were analyzed. Mean stenosis was 84.41% pre-intervention and 6.83% post-intervention. Five of the procedures were angioplasty alone; 38 were angioplasty with stenting. Technical success was achieved in 42 out of 43 patients. The 30-day mortality rate was 0%. At one-month post intervention, all patients were symptom free. Ten patients redeveloped symptoms by one year. Demographic data, patient comorbidities, and indication to treat were analyzed. It was found that prior coronary intervention led to a statistically significant higher rate of symptom reoccurrence (p = 0.036). Additionally, a divergence in the rate of symptom reoccurrence based on indication to treat SAS was noted with the highest rate of symptom reoccurrence in the pre-coronary artery bypass grafting (CABG) group and the lowest rate of symptom reoccurrence in the subclavian steal syndrome (SSS) group. The coronary subclavian steal (CSS) group had an intermediate rate of symptom reoccurrence. During this time period, 1154 CABGs were performed. Flow-limiting stenosis was noted on angiography in 17 of these patients, giving pre-CABG prevalence of 1.46%.

Arterial steal syndrome after orthotopic liver transplantation (OLT) is characterized by arterial hypoperfusion of the graft, which is caused by a shift in blood flow into the splenic or gastroduodenal arteries. In this report, we present mechanisms by which this syndrome caused ischemia in our patients. Steal was suspected by elevated levels of liver enzymes and the results of Doppler ultrasonography and computed tomographic angiography; it was confirmed by celiac angiography. Patients with established hepatic arterial thrombosis before angiography were excluded from this study. Steal was treated by embolization with a coil or by placement of an endoluminal narrowing stent. Ten patients at our institution (seven men and three women; mean age, 24.7 +/- 11 years; range, 6 to 40 years) exhibited biochemical evidence of liver ischemia and graft failure at 1 to 170 days after having undergone orthotopic liver transplantation. Nine of those patients had splenic steal, and one had both splenic and left gastric artery steal syndrome. None of the patients had gastroduodenal artery steal syndrome. The eight patients with splenic steal syndrome and the patient with both splenic and left gastric steal syndrome were treated by transcatheter occlusion with a coil. The remaining patient with splenic steal syndrome was treated with an endoluminal narrowing stent placement. All patients improved clinically within 24 hours after treatment, exhibiting significant changes in their biochemical and radiological parameters. Follow-up ranged from 1 to 22 months (mean, 6.7 +/- 6.6 months). One patient died from sepsis 1 month after having undergone coil embolization. He had no vascular anomalies at the time of death. We conclude that steal is a significant problem after OLT. Embolization and stenting are minimally invasive and successful treatments for steal, usually resulting early clinical improvement.

Dialysis-associated steal syndrome (DASS) is defined as a clinical condition caused by arterial insufficiency distal to the dialysis access owing to diversion of blood into the fistula or graft. The incidence of symptomatic DASS requiring treatment is 1-8%. The etiology is iatrogenic and symptoms are quite debilitating. Banding of the access inflow has largely been abandoned because of the inherent problem with balancing fistula flow with distal flow complicated by a high incidence of subsequent access thrombosis. In this study, we are reporting a modification to the traditional banding procedure, which markedly improves banding outcomes. We are reporting 16 patients who underwent a new standardized minimally invasive banding procedure performed in an outpatient setting with minimal morbidity. This modified banding procedure requires a small (1-2 cm) skin incision for the placement of a ligature and utilizes a 4 or 5 mm diameter endoluminal balloon to achieve and standardize the desired reduction of inflow size. All 16 patients had immediate symptomatic and angiographic improvement after the procedure. Follow-up showed none of the patients had recurrence of symptoms or thrombosis of the access. In our experience, this procedure is an excellent treatment option because of its simplicity and should be considered as a first-line treatment for patients with DASS.

Objectives: The objective was to assess the prevalence of subclavian artery stenosis (SS) in four cohorts (two free-living and two clinical populations) and determine both risk factors for this condition and the association with other cardiovascular conditions., Background: The prevalence of SS in the general population is unknown, and its association with risk factors and other cardiovascular diseases is not well-established., Methods: A total of 4,223 subjects (2,975 from two free-living cohorts and 1,248 from two clinical cohorts) were included in this cross-sectional analysis. Subclavian artery stenosis was defined as > or =15 mm Hg interarm pressure difference., Results: The prevalence of SS was 1.9% in the free-living cohorts and 7.1% in the clinical cohorts; SS was significantly (p < 0.05) associated with past smoking (odds ratio [OR] = 1.80), current smoking (OR = 2.61), and higher levels of systolic blood pressure (OR = 1.90 per 20 mm Hg). Higher levels of high-density lipoprotein (HDL) cholesterol were inversely and significantly associated with SS (OR = 0.87 per 10 mg/dl). In regression analyses relating SS to other cardiovascular diseases, the only significant finding was with peripheral arterial disease (PAD) (OR = 5.11, p < 0.001)., Conclusions: Significant SS is present in approximately 2% of the free-living population and 7% of the clinical population. Additionally, SS is correlated with current and past smoking histories, systolic blood pressure, HDL levels (inversely), and the presence of PAD. These findings suggest that bilateral brachial blood pressure measurements should routinely be performed in patients with an elevated risk profile, both to screen for SS, and to avoid missing a hypertension or PAD diagnosis because of unilateral pressure measurement in an obstructed arm.

Context: The majority of patients with Hodgkin lymphoma are young and highly curable. This necessitates concern for prevention, diagnosis, and optimal management of potential treatment-related complications., Objective: To identify and quantify the incidence of and factors contributing to long-term cardiac and vascular complications after radiation therapy for Hodgkin lymphoma., Design and Setting: Retrospective study comparing patients treated from 1962 to 1998 at a university-based referral center with a matched general population., Patients: Four hundred fifteen consecutive patients who fulfilled the inclusion criteria of a minimum 2-year follow-up (median, 11.2 years) and whose radiation fields included the heart or carotid or subclavian arteries., Main Outcome Measures: Multivariable analyses of potential risk factors and observed-to-expected ratios for cardiac valve surgery, coronary artery bypass graft surgery, percutaneous coronary intervention, or both based on Surveillance, Epidemiology, and End Results (SEER) and National Hospital Discharge Survey (NHDS) data., Results: Forty-two patients (10.4%) developed coronary artery disease at a median of 9 years after treatment, 30 patients (7.4%) developed carotid and/or subclavian artery disease at a median of 17 years after treatment, and 25 patients (6.2%) developed clinically significant valvular dysfunction at a median of 22 years. The most common valve lesion was aortic stenosis, which occurred in 14 valves. The observed-to-expected ratio for valve surgery was 8.42 (95% confidence interval [CI], 3.20-13.65) and the observed-to-expected ratio for coronary artery bypass graft surgery or percutaneous coronary intervention was 1.63 (95% CI, 0.98-2.28). At least 1 cardiac risk factor was present in all patients who developed coronary artery disease. The only treatment-related factor associated with the development of coronary artery disease was utilization of a radiation technique that resulted in a higher total dose to a portion of the heart (relative risk, 7.8; 95% CI, 1.1-53.2; P =.04). No specific treatment-related factor was associated with carotid or subclavian artery disease or valvular dysfunction. Freedom from any cardiovascular morbidity was 88% at 15 years and 84% at 20 years., Conclusions: Among patients treated with radiation therapy for Hodgkin lymphoma, there are statistically higher than expected rates of valve surgery and coronary revascularization procedures over the next 10 to 20 years. Coronary vascular disease is associated with higher radiation doses and traditional coronary heart disease risk factors. Noncoronary vascular disease and clinically important valvular dysfunction are less well understood complications at 15 to 20 years after radiation, requiring surveillance and further study.

Introduction: Steal syndrome is a potentially grave complication of upper extremity hemoaccess (HA) in patients with renal failure. To determine the incidence and risk factors for steal in these patients at the St. Boniface Hospital, Winnipeg, a tertiary care centre for vascular surgery and dialysis, we reviewed data from patients requiring hemodialysis between September 1986 and July 2000., Patients and Methods: We excluded all venous catheter and lower extremity procedures. There remained 325 upper extremity procedures in 217 patients. Data were collected from the patients' charts or by interview. First by univariate analysis and then by multivariate analysis for independent risk factors, we studied the effect on the development of steal of age, sex, race diabetes mellitus, hypertension, coronary artery disease or cerebrovascular disease, smoking, proximal procedures based on the brachial artery, distal procedures based on the radial artery, the use of prosthetic graft material and the creation of autologous fistulas., Results: The incidence of steal was 6.2%. The significant independent risk factors were diabetes mellitus (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.39-18.08, p = 0.01) and Aboriginal race (OR 3.59, 95% CI 1.07-12.04, p = 0.04). An increasing risk for each year of advancing age at the time of procedure was suggested but was not significant (OR 1.04, 95% CI 1.00-1.09 p = 0.07)., Conclusions: Patients who are diabetic or Aboriginal are at increased risk for steal with upper extremity HA procedures. This knowledge can guide discussion of dialysis options and informed consent. If upper extremity HA procedures are undertaken in patients at risk, they should be closely monitored and early intervention applied if necessary.

Objective: To determine the incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis (GCA)., Methods: The cohort of all residents of Olmsted County, Minnesota, in whom GCA was diagnosed between January 1, 1950, and December 31, 1999, was followed up. The incidence of aortic aneurysm, aortic dissection, and large-artery stenosis was determined. Possible predictors and correlates of large-artery complication were assessed., Results: Forty-six incident cases of large-artery complication (representing 27% of the 168 patients in the cohort) were identified. These included 30 incident cases (18%) of aortic aneurysm and/or aortic dissection. Of these cases, 18 (11%) involved the thoracic aorta, with aortic dissection developing in 9 (5%). There were 21 incident cases (13%) of large-artery stenosis. Fifteen patients (9%) had incident cervical artery stenosis, and 6 (4%) had incident subclavian/axillary/brachial artery stenosis. One patient (0.6%) had incident iliac/femoral artery stenosis attributable to GCA. Hyperlipidemia and coronary artery disease were associated with aortic aneurysm and/or dissection (P < 0.05 for both). Cranial symptoms (headache, scalp tenderness, abnormal temporal arteries) were negatively associated with large-artery stenosis (hazard ratio [HR] 0.10 [95% confidence interval (95% CI) 0.03-0.35, P < 0.0005]), as was a higher erythrocyte sedimentation rate (HR 0.80 [95% CI 0.67-0.95, P < 0.05] per 10 mm/hour)., Conclusion: Large-artery complication is common in GCA. Increased awareness of large-artery complication in GCA, particularly early-occurring aortic dissection, may decrease associated mortality.

Percutaneous transluminal angioplasty (PTA) is a well-established treatment for patients with subclavian artery stenosis and brachial or cerebral symptoms. Its efficacy for treatment of subclavian occlusions, however, is not yet established. We attempted to recanalize the subclavian artery in 46 patients with proximal subclavian artery occlusion and were successful in 38 (83%). In two patients, residual stenosis, and in five patients, thrombotic material on the arterial wall required subsequent implantation of a self-expandable stent. Two additional patients were left with residual stenoses because stents were not available at that time. There were no cerebral or brachial complications. During a mean follow-up of 33 months, occlusion recurred in one patient after 3 months and stenosis recurred in five.

In order to assess the therapeutic outcome of percutaneous transluminal angioplasty for subclavian stenosis, 50 patients were followed up clinically as well as with a velocimetric Doppler after attempted angioplasty. A minimal clinical follow-up of 9 months was expected. Subclavian stenoses were due to atheroma in 49 patients and to Takayasu's disease in 1 case. Indication of angioplasty was curative in 34 (68%) symptomatic patients (posterior fossa ischemia and/or upper limb ischemia) and preventive in 16 (32%) asymptomatic patients (severe difference of blood pressure between the 2 arms and/or association with carotid stenosis or axillo-femoral bypass). Angioplasty was successful in 45 patients (primary success rate = 90%). Three (6%) thrombosis occurred due to the percutaneous approach, one of the axillary and one of the brachial artery without any significant sequelae, and one of the aorta requiring an aorto-bifemoral bypass. A complication occurred in 2 unsuccessful angioplasties (4%): an ischemic stroke occurred in 1 case and a thrombosis of the dilated site requiring a surgical bypass. Clinical follow-up over a period of 9-101 months (mean = 41) was performed in 43 out of the 45 patients who had undergone angioplasty successfully. Two patients had a follow-up shorter than 9 months: one died after 5 months, the other was lost to follow-up. By the end of the clinical follow-up, 37 (84%) out of the 44 followed-up patients had benefitted from the procedure. Doppler study performed in 35 out of the 44 followed-up patients (80%) over a period of 2-90 months (mean = 39) showed 5 restenosis (14%). This study demonstrates the good long-term results of angioplasty in case of subclavian artery stenosis. Though there are complications, angioplasty could be proposed as a first choice treatment for subclavian stenosis as compared to surgery. Indications in asymptomatic patients should be carefully weighed as complications may occur.

To determine the importance of carotid artery disease in patients undergoing revascularization of the proximal subclavian artery for a subclavian steal syndrome, an 18-year experience of 55 patients was reviewed. Concomitant carotid artery disease (> 50% stenosis) was present in 35 patients (Group I: 63.6%). Twenty patients (Group II: 36.4%) had no evidence of hemodynamically significant carotid disease. Twenty-five patients in Group I (Group IA: 71.4%) were treated by endarterectomy (CEA) for all their carotid lesions while one or both carotid lesions were left untreated in 10 patients (Group IB: 28.6%). The actuarial 5-year freedom rate from neurological events was 87.2% in Group IA, 34.9% in Group IB (p < 0.001) and 100% in Group II (Group IB vs. II, p < 0.001; Group IA vs. Group II, p = ns). All untreated carotid lesions had a deleterious effect on the early and late functional results after surgical reconstruction of the subclavian artery. We conclude that the combined correction of subclavian and carotid lesions should be recommended in every case.

Continuous-wave (CW) Doppler sonography has proved to be a reliable tool both to detect subclavian stenosis or occlusion and to detect reversal of blood flow in the vertebral artery. This method is entirely atraumatic and in contrast to angiography allows investigation of asymptomatic patients and provides more representative data for epidemiological studies. The incidence of subclavian stenosis or occlusion was 1.15% among the 23,500 patients examined in our department between 1978 and 1985. Of the 272 patients with unilateral or bilateral subclavian stenosis or occlusion, 54% were asymptomatic with no subjective complaints and were normal upon neurological examination; 29% reported vertebrobasilar transient ischaemic attacks (TIAs), with or without concomitant TIAs or infarction in the vascular territory of the carotid arteries; and 17% complained of symptoms exclusively referring to the region of carotid blood supply. Reversal of blood flow in the ipsilateral vertebral artery was detected in 152 patients (56%). The incidence of neurological symptoms within this group was double that found in patients without steal. None of the patients suffered from permanent vertebrobasilar damage. In most cases, subclavian artery disease was due to atherosclerosis. For 13 patients an inflammatory, iatrogenic, traumatic, or congenital aetiology could be assumed. The marked preponderance of left-sided subclavian stenosis or occlusion, reported by others, could be confirmed among our patients, but was less pronounced for tight stenoses than for occlusions. Mild-to-moderate subclavian stenoses were about equally distributed on each side.

Among 337 male patients who were hospitalized because of chronic ischemia of the leg, 103 (=30.6%) were shown to suffer from concomitant occlusive vascular disease of supraaortic branches. This was evaluated by simple examination like auscultation, bilateral blood pressure measurements, and palpation of pulses. In 52% the patients history revealed dizziness, hemiparesis and transient ischemic attacks (TIA). Arteriell hypertension promotes supraaortic vascular diseases as is shown by a relative frequency of 0.52 in contrast to 0.39. Combined occlusions of the iliac and femoropopliteal arteries are accompanied by supraaortic vascular disease in 40%, in femoropopliteal occlusion alone in only 20%. If the basic diagnostic approach is improved by directional ultra-sonic examinations of the carotid arteries, approximately 20% of all patients with advanced vascular disease of the iliac and femoropopliteal arteries have to be operated on for cerebrovascular disease.