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 Innominate, Subclavian and Vertebrobasilar Arterial Disease

Ramon Berguer, M.D., Michael DaValle, M.D., Francis Robicsek, M.D.

Includes:

  • Stenotic and Embolic Innominate Artery Disease
  • Stenotic and Embolic Vertebral Artery Disease
  • Stenotic and Embolic Subclavian Artery Disease
  • Subclavian Steal Syndrome
  • Additional Important/Non-Core Cirriculum Topics:
  • Vertebral Arteriovenous Fistulae

I. Etiology, Pathophysiology and History

1. Pathophysiology of atherosclerosis, trauma, dissection, arteritis and radiation as it applies to the in nominate, subclavan and vertebrobasilar arteries.

2. Concomitant diseases and associated risk factors commonly associated with stenosis, occlusion, dissection, ulcerated atheroma, arteriovenous fistula and false aneurysm of these arteries.

3. Define the most appropriate diagnostic steps for the evaluation and for the choice of treatment of these conditions.

4. Abnormal and alternative flow patterns that may develop as a consequence of lesions of the innominate, subclavian and vertebrobasilar arteries.

5. Best diagnostic methods available to assess end-organ effects in the brain and upper extremities of the lesions mentioned above.

6. Natural history of these conditions and how this natural history is affected by treatment methods when the latter are successful and when they fail.

II. Diagnosis

1. Symptoms and signs of brain ischemia in its various manifestations, localized and global, progressive and sudden.

2. Symptoms of ischemia of the upper extremity.

3. Signs of ischemia of the brain or upper extremities elicited by provocative maneuvers .

4. Understand the differential diagnosis of conditions that may present with similar signs or symptoms.

5. Understand how noninvasive tests may suggest or deny the presence of lesions of the innominate, subclavian and vertebrobasilar arteries and how these tests may preclude or indicate arteriography.

6. Understand the anatomy of these arteries and their lesions as defined by arteriography, the timing of films and the best projections to display them.

7. Know the risks involved in arteriography relative to the contrast agents used and their amount, the approach used and the pharmacologic and technical maneuvers employed.

8. Value and shortcomings of CT and MRA/MRI imaging techniques in the diagnosis of these entities.

III. Treatment

1. Options for (a) medical treatment (antiplatelet, anticoagulant, steroids, antiinflammatory drugs), (b) surgical repair whether direct (endarterectomy, transposition, ligation) indirect (bypass, decompression) or (c) endovascular (angioplasty, stenting, covered stents).

2. Indications for combined treatment and their timing.

3. Possible complications of each of the above treatments and their management.

4. Long-term results with the different treatment options.

References

1. Kieffer E, Sabatier J, Koskas F, Bahnini A. Atherosclerotic innominate artery occlusive disease: early and long-term results of surgical reconstruction. J Vasc Surg 21(2):326-37, 1995.

2. Owens LV, Tinsley EA Jr, Criado E, Burnham SJ, Keagy BA. Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks. J Vasc Surg 22(3):217 - 22, 1995.

3. Berguer R, Kieffer E: SURGERY OF THE ARTERIES TO THE HEAD, Springer-Verlag New York Inc., New York , 1992.

Posted June 2010