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Comparing Percutaneous Transluminal Angioplasty and Stent Placement for Treatment of Subclavian Arterial Occlusive Disease: A Systematic Review and Meta-Analysis. Cardiovasc Intervent Radiol 2016; 39:652. 62. Filippo F, Francesco M, Francesco R, et al. Percutaneous angioplasty and stenting of left subclavian artery lesions for the treatment of patients with concomitant vertebral and coronary subclavian steal syndrome. Cardiovasc Intervent Radiol 2006; 29:348. Topic 8183 Version 19.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 16/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate GRAPHICS Anatomy of the cerebral arterial circulation Frontal view of the carotid arteries, vertebral arteries, and intracranial vessels and their communication with each other via the circle of Willis. Reproduced with permission from: U acker R. Atlas Of Vascular Anatomy: An Angiographic Approach, Second Edition. Philadelphia: Lippincott Williams & Wilkins, 2006. Copyright 2006 Lippincott Williams & Wilkins. Graphic 51410 Version 6.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 17/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Subclavian steal Subclavian artery occlusion or a hemodynamically significant stenosis proximal to the origin of the vertebral artery results in lower pressure in the distal subclavian artery. As a result, blood is "stolen" from the cerebral circulation to perfuse the arm. Blood flows up the contralateral vertebral artery to the basilar artery, and retrograde down the ipsilateral vertebral artery away from the brainstem. Graphic 62622 Version 6.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 18/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Coronary steal physiology In coronary-subclavian steal, severe stenosis or occlusion of the left subclavian artery proximal to the origin of a left internal mammary-to- coronary artery bypass graft may cause "steal" from the coronary graft to maintain perfusion to the arm via the left subclavian artery during upper extremity exercise. Graphic 76733 Version 3.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 19/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Collateral circulation around the shoulder The thyrocervical trunk, dorsal scapular artery, and internal thoracic artery provide important collateral channels of blood flow to the ipsilateral brain and upper extremity when a significant stenosis or occlusion of the brachiocephalic or subclavian artery is present. Graphic 66933 Version 4.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 20/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Anatomy of the thoracic outlet The thoracic outlet refers to the confined space between the clavicle and first rib. Structures that pass through this region include the nerves of the brachial plexus, the subclavian artery, and the subclavian vein. Graphic 59433 Version 7.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 21/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Radial pulse delay in subclavian steal syndrome Simultaneous right and left radial pulse volumes in a patient with dizziness induced by left upper extremity exercise shows late arrival of the left subclavian artery pulsation, which can be appreciated by simultaneous palpation of the radial arteries. Note the delay in the left radial pulse at the brown bar. Courtesy of Peter Spittell, MD. Graphic 61635 Version 4.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 22/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Arteriogram of the aortic vessels in subclavian steal (A) Arteriography of the aortic arch vessels demonstrates a significant stenosis of the proximal innominate artery. (B) Reversal of flow in the right vertebral artery. Courtesy of Peter Spittell, MD. Graphic 63380 Version 7.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 23/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Vertebral artery flow in subclavian steal syndrome The pulse-waved Doppler spectral display shows retrograde flow in the left vertebral artery in a patient with a hemodynamically significant left subclavian artery stenosis. Courtesy of Peter Spittell, MD. Graphic 80201 Version 3.0 https://www.uptodate.com/contents/subclavian-steal-syndrome/print 24/25 7/6/23, 12:36 PM Subclavian steal syndrome - UpToDate Contributor Disclosures John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. 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