课件：锁骨下动脉窃血综合征解析.ppt

Case discussion,Bone group 2012.6.7,History,Male ，62 years old A transient syncope Sphygmus ：72 times/min，left-weak Blood pressure ：right arm110/70 mmHg left arm70/50 mmHg,Possible diagnosis？ Why ？,Final diagnosis,Image impression：Subclavian artery wall calcification , stenosis ； thrombosis can not be excluded Clinical diagnosis ： Subclavian Steal Syndrome (SSS),Subclavian Steal Syndrome,Definition ： Subclavian steal syndrome is the proximal subclavian artery or innominate artery obstruction（ caused by a variety of reasons），Subclavian artery distal intraluminal pressure decreased ，ipsilateral blood pressure below the vertebral basilar arterial pressure - syphonage ，so result in SSS,Clinical manifestations,upper limb symptom：Some patients complained of weakness, numbness and pain when the upper limbs exercise Vertebrobasilar insuficiency symptom： Syncope, dizziness, vertigo, standing instability and occipital pain is the most common complaint carotid artery insufficiency symptom： rarely ，but can occur in the patient of innominate artery obstruction,Physical findings,Ipsilateral radial artery pulse weakened or disappeared, bilateral pulse nonsynchronization (delay 0.03 0.06s） Pressure differential (PD) 20 mmHg （ contralateral Ipsilateral ） （Only 16% of the patients with a PD 20mm Hg did not have SSS. This result suggests that arm BP differential 20mmHg is highly correlated with the presence of SSS）,Physical findings,The ipsilateral supraclavicular fossa vascular bruit (systolic) Javid test： positive (after the oppression of the common carotid artery, radial artery pulse weakened),Pathogeny,Arteriosclerosis （most common） Congenital malformations (aortic stenosis , subclavian artery distal atresia ) Takayasu arteritis (tuberculosis, syphilitic aortitis) Tumor compression Radiotherapy,SSS blood pathway（一） VAVA,contralateral vertebral artery vertebrobasilar artery confluence ipsilateral vertebral artery ipsilateral subclavian artery distal,SSS blood pathway（二） BAVA,basilar artery ipsilateral vertebral artery ipsilateral subclavian artery distal,SSS blood pathway（三） PCABAVA,posterior cerebral artery basilar artery ipsilateral vertebral artery ipsilateral subclavian artery distal,SSS blood pathway（四） OAVA,external carotid artery branch occipital artery occipital artery and vertebral artery anastomotic branch vertebral artery subclavian artery distal,Diagnostic methods（一）,Doppler ultrasound examination Observe the blood flow Vertebral artery appearing reverse spectrum is the typical performance of SSS,A, Normal flow in a patient without subclavian steal syndrome (SSS). It has a low wave pattern resistance with cephalad flow throughout the cardiac cycle. B, Flow velocity waveform in the left vertebral artery indicating a partial SSS. The flow during systole and the beginning of diastole is reversed. There was a 25 mm Hg PD. C, Complete steal in a patient with arm blood PD of 60 mm Hg. The flow in the vertebral artery is reversed throughout the cardiac cycle.,The severity can be graded based on the vertebral Doppler spectral patterns:,I： antegrade flow with diminished peak systolic velocity II：alternating flowantegrade flow in the diastolic phase and retrograde flow in the systolic phase III：completely retrograde flow,Diagnostic methods（二）,Digital Subtraction AngiographyDSA DSA - the gold standards to diagnose SSS the degree of Subclavian artery stenosis the location of subclavina artery the progress of the reflux blood flow （ the contralateral vertebral artery the ipsilateral vertebral artery the ipsilateral subclavian artery distal） limition expensive, invasive，difficult to repeat sensitive to completed stenosis ，but not to partial stenosis,A digital subtraction angiogram confirmed a high-grade stenosis at the proximal left subclavian artery.,The left VA was concealed in the left subclavian arter angiogram ，but could be outlined by retrograde filling of contrast from the right VA.,After angioplasty of the left subclavian artery stenosis, the left VA reappeared in the left subclavian artery angiogram as blood flow resumed antegrade.,Diagnostic methods（三）,Multi-slice spiral CT angiography (MS-CTA) Preoperation- etiological diagnosis localize comfirm a clinically suspected stenosis exclude further stenoses depict collateral circulation Postoperation exclusion or quantification of clinically suspected restenosis in patients after endovascular therapy （ultrasound is inconclusive and/or contrast-enhanced magnetic resonance angiography is contraindicated）,Diagnostic methods（四）,TOF-MRA: PC-MRA( flow analysis)： CE-MRA:,TOF,CE,CE,PC,Treatment,SSS is frequently observed in patients undergoing carotid duplex scanning. It is usually asymptomatic and rarely requires intervention. The decision to intervene is mainly symptom driven. Patients with subclavian artery stenosis have a higher incidence of generalized atherosclerotic disease.,Treatment,Conservative therapy Surgery： Endarterectomy Intravascular trip stenting the femoral artery path Ipsilateral arm artery path,Aortic arch angiography, the left subclavian artery stenosis, the left vertebral artery not develop,Right vertebral artery angiography, the imaging of the left vertebral artery develop from distal to proximal-SSS,Takaya suarteritis, TA,Refers to the aorta and its main branches of the chronic non-specific inflammatory disease. lesions in the aortic arch and its main bra