Copyright © 2012 Jiri Mandak et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Coronary subclavian steal syndrome with retrograde blood flow in the left internal mammary-coronary bypass graft is a rare but severe complication of cardiac surgery. The authors present a case of a 68-year-old man after coronary-artery bypass grafting using an internal mammary artery. He had been suﬀering from angina pectoris for the last several years before surgery. The patient was resuscitated at home by emergency medical service because of primary ventricular fibrillation due to an acute myocardial infarction 5 years after surgery. An occlusion of the left subclavian artery with the retrograde blood flow in the left internal mammary coronary bypass was found. This could have been the cause of insuﬃciency in coronary blood flow and ischemia of the myocardial muscle. The subclavian artery occlusion was successfully treated with percutaneous transluminal angioplasty and implantation of 2 stents. The patient remained free of any symptoms 2 years after this procedure.
Subclavian steal syndrome (SSS) is defined as a group of symptoms that arise from reversed blood flow in the ipsilateral vertebral artery. It is the consequence of proximal occlusion or high- grade stenosis of the subclavian artery. The subclavian obstructive lesions are mostly lo- cated in the proximal segment of the subclavian artery and predominantly on the left side. In contrast, there are only a small number of pa- tients that present with right-sided symptoms and even fewer with bilateral symptoms. Endo- vascular therapy of occlusions and high-grade stenosis of subclavian artery proximal to the origin of the vertebral artery becomes an estab- lished therapy in last two decades. We report a case of successful endovascular treatment of right-sided subclavian steal and high-grade (80%) right subclavian artery stenosis due to atheros- clerotic occlusive disease with balloon-ex- pandable stent using brachial approach.
1. Chung JW, Kim HC, Choi YH, Kim SJ, Lee W, Park JH. Patterns of aortic involvement in Takayasu arteritis and its clinical implications: evaluation with spiral computed tomography angiography. J Vasc Surg 2007;45:906–914. 2. Labropoulos N, Nandivada P, Bekelis K. Prevalence and impact of the subclavian steal syndrome. Ann Surg 2010; 252:166–170.
Obstructive lesions of the innominate artery occur more proximally than those leading to subclavian steal syn- drome. The resulting inflow compromise of both subcla- vian and common carotid arteries is responsible for the higher incidence of symptomatic disease among patients with innominate artery lesions. The spectrum of manifes- tations ranges from upper extremity exercise-induced ischemia to cerebrovascular insufficiency. Obstruction of the innominate artery not affecting the origin of the sub- clavian and common carotid arteries allows free commu- nication between these vessels, which receive a substantial part of their arterial supply from collateral circulation. The combination of disturbed arterial inflow, along with dif- ferences between vascular resistances of the cerebral and upper extremity vascular beds, is responsible for a com- plex blood flow relationship giving birth to partly or totally abnormal vascular flow directions in the involved vessels. Since, during innominate artery occlusion, right sided cerebral blood flow is achieved by means of collat- eral routes involving the circle of Willis, and diversion of flow across the vertebrobasilar junction is more effective than across the circle of Willis , a permanent retrograde blood flow in the right vertebral artery (Figure 3) and a transient mid-systolic blood flow reversal in the common and internal carotid arteries (Figure 1) are observed. A recent report showed that complete occlusion of the right vertebral artery was the cause for the so called innominate disease phenomenon .
Subclavian steal syndrome is a constellation of signs and symptoms that arise from retrograde flow of blood in the vertebral artery due to ipsi- lateral arm exercise or exertion. The symptoms, including diplopia, dizziness, vertigo, syncope and dysarthria, are indications of vertebrobasi- lar ischemia caused by diminished blood pres- sure due to a proximal stenosis or occlusion of the subclavian artery . The risk factors for subclavian steal syndrome are thus similar to those of atherosclerotic diseases including smoking, hyperlipidemia, hypertension, diabe- tes mellitus, family history and aging process. Patients older than 50 years are more likely to have subclavian steal syndrome, possibly due to the increased atherosclerosis in this age phase. Here, we reported a case of right sub- clavian artery stenosis associated with subcla- vian artery aneurysms with symptoms of sub- clavian steal syndrome. The successful angio- plasty and stenting of a right subclavian artery stenosis were reported.
ABBREVIATIONS: ACA ⫽ anterior cerebral artery; AVF ⫽ arteriovenous fistula; AVM ⫽ arterio- venous malformation; bpm ⫽ beats per minute; CBF ⫽ cerebral blood flow; CBV ⫽ cerebral blood volume; CE ⫽ contrast enhanced; CTA ⫽ CT angiography; DSA ⫽ digital subtraction angiography; ECA ⫽ external carotid artery; fps ⫽ frames per second; fpVCT ⫽ flat panel volume CT; ICA ⫽ internal carotid artery; IVC ⫽ inferior vena cava; MDCT ⫽ multidetector row CT; MIP ⫽ maximum intensity projection; MTT ⫽ mean transit time; NZW ⫽ New Zealand white; RCCA ⫽ right common carotid artery; SRAC ⫽ Subcommittee on Research Animal Care; SSS ⫽ subclavian steal syndrome
Stentgraft deployment was successful in all cases (Ta- bles 1 and 2). Thrombosis or shrinkage of pseudoaneury- smal sacs was achieved in 6 cases (85%) within 1 week after treatment (Figure 1). In 1 patient with esophageal cancer (Case 4; Figure 2), rebleeding from the tra- cheostomy hole occurred 13 days after treatment and he died of this bleeding. In other 6 patients (85%), throm- bosis of the aneurysmal sac or hemostasis was main- tained during follow-up (range, 90 - 1094 days). In cases of blunt injury of the brachiocephalic artery (such as Case 5 in this series), deployment of a stentgraft is ha- zardous at the bifurcation between the carotid and sub- clavian arteries, due to the potential for obstruction of the carotid artery or brain embolism. We deployed the stent- graft between the carotid and brachiocephalic arteries to maintain blood flow to the brain. Following this pro- cedure, coil embolization of the right subclavian artery was performed. Hemostasis was achieved later. Despite embolization of the right subclavian artery, blood flow to the right arm was compensated via retrograde flow from the vertebral artery. We performed a 4-vessel study be- fore this procedure, but did not consider using a balloon occlusion test of the subclavian artery due to the risk of traumatic injury to the brachiocephalic artery. During follow-up, this patient did not complain of symptoms associated with complications such as subclavian steal syndrome.
A potential etiology of dopamine fluctuations was not defined until 2012. This paper documents the current knowledge regarding this phenomenon as associated with the treatment of Parkinson’s disease. The primary hypothesis is that if significant retrograde phase 1 urinary dopamine fluctuations exist in the competitive inhibition state, then the primary force causing this phenomenon is melanin steal, which causes dopaquinone to preferentially utilize L-tyrosine and L-3,4-dihydroxyphenylalanine (L-dopa), leading to an inconsistency of dopamine synthesis.
The ventral, and proximal, entry point of the vascular sheath into the subclavian artery raised some very interest- ing clinical scenarios. In order to surgically extract the catheter and control any subsequent hemorrhage an extensive resection of the manubrium, medial clavicle and medial first rib would be required. Consultation with a peripheral vascular surgeon determined that this could be performed, but the consequent morbidity and mortality due to the nature of the proposed surgery and the exten- sion of an already protracted general anesthetic (6 hours), made this a very unattractive alternative.
This is to certify that the dissertation presented “COMPARISON OF LATERAL APPROACH AND SUBCLAVIAN PERIVASCULAR APPROACH OF SUPRACLAVICULAR BLOCK”herein by Dr. M.S.PRABHU is an original work done in the Department of Anaesthesiology, Government Stanley Medical College and Hospital, Chennai in partial fulfilment of regulations of the Tamilnadu Dr. M.G.R. Medical University for the award of degree of M.D. (Anaesthesiology) Branch X, under my supervision during the academic period 2010-2013.
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Stead’s fictional Banque Mercure affords at once a synecdoche for the new global force, finance capital, and the means of its demystification. In particular, her novel targets banking’s claim to prudent, productive capital outlays, as well as offers a damning encapsulation of the typical strategies and class objectives of its directors. Her bank’s identification with the Roman god Mercury suggests a number of the industry's important features: volatility, a reliance on luck, and a tacit identification with the patron god of thieves. As its director, Jules Bertillon, happily asserts: “Money isn’t respectable. Money is a steal” (House of All Nations 676). Admittedly, his bank draws its clientele exclusively from a leisured élite, with adequate funds to speculate, making it a condensed or “telescoped bank” (550). This, however, represents an important though often invisible section of a major bank’s business (“we do things on the first floor that they do on the fiftieth story in a fine New York bank” ), while more generally it foregrounds the sector’s dependence on client gullibility and its ruthless drive for profit. A sumptuous interior creates an exclusive, club-like atmosphere, glittering market quotations entertain as well as energise the gambler-clients, and furnishings are arranged so that staff and customers look at their best. A massive glass canopy seems to promote transparency, while out of sight a labyrinth of concealed, secret passages suggests the nefarious, nether side of banking. Hence the premises can be described as a “strange palace of illusion, temptation, and beauty” (198)—in a scarcely veiled warning about the delusive nature of the whole enterprise.
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and decrease the risk of injuring important surrounding structures, such as the subclavian vein or brachial plexus, which may be difficult to identify because of haemorrhage or involvement in the original injury . High success rates can be achieved if the lesion is focal and can be tra- versed safely with a guidewire. Complete vessel transec- tion has been reported as a common cause for failure of an endovascular approach, primarily due to difficulty with crossing the complete transection and its associated hematoma . As such, vessel transection has traditionally been approached with open vascular reconstruction. It seems convenient to perform a femoral artery access in a trauma setting, for the possibility to perform selective arteriographies of abdominal viscera. Even though rare tortuosity of supra-aortic vessels could be an obstacle for catheterization, the femoral access offers the possibility to use devices of different dimensions (until 7 F), represent- ing the standard access for this procedure. The brachial access still offers a valid alternative in case of difficult sub- clavian catheterization and provides the opportunity to perform a combined brachial and femoral access to create a through-and-through brachial-femoral wire and repair of transected mid-to-distal subclavian or axillary artery with covered stent, as described by Shalhub and coll. in their recent work .
Background: Isolation of Left Subclavian Artery (LSCA) is a rare subset of Right Aortic Arch (RAA). It is diagnosed as nonvisualization of LSCA in ca- theterization study. Case Presentation: Here we report an unusual case of Tetralogy of Fallot (TOF) with right aortic arch with isolation of left subcla- vian artery (LSCA). Here LSCA originated from left pulmonary artery (LPA) through an atretic patent ductus arteriosus (PDA). There was nonvisualiza- tion of LSCA in catheterization study and it was confirmed by Computed Tomography (CT) angiography. Re-implantation of LSCA was done to left common carotid artery (LCCA) so that the left upper arm maintains a better flow in the future. Conclusion: Isolation of LSCA especially with TOF is a very rare entity. Re-implantation of LSCA to LCCA was done in view of weak pulses in left upper limb. Results were satisfactory in the follow up pe- riod.
This game could also be written in extensive form (i.e., as a game tree), whereby A makes a decision after learning the outcome of the 2 ´ 2 game. But the normal form (i.e., as a payoff matrix) makes it easier to compare with the earlier 2 ´ 2 game and the final game we discuss in the next section. Notice that, as in Game 1, each player does best when he wins the entire jackpot (4), next best (3) when there is a split, next worst (2) when both players Steal and there is nothing to split, and worst (1) when one wins the entire jackpot and the other nothing.
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State legislators, librarians, PTA members, FBI agents, church-goers, and parents: a veritable legion of decency and order already is on the march. To get the book to you might be the biggest challenge we face. The next few months should prove really exciting. Obviously such a project as Steal This Book could not have been carried out alone. Izak Haber shared the vision from the beginning. He did months of valuable research and contributed many of the survival techniques. Carole Ramer and Gus Reichbach of the New York Law Commune guided the book through its many stages. Anna Kaufman Moon did almost all the photographs. The cartoonists who have made contributions include Ski Williamson and Gilbert Sheldon. Tom Forcade, of the UPS, patiently did the editing. Bert Cohen of Concert Hall did the book's graphic design. Amber and John Wilcox set the type. Anita Hoffman and Lynn Borman helped me rewrite a number of sections. There are others who participated in the testing of many of the techniques demonstrated in the following pages and for obvious reasons have to remain anonymous. There were perhaps over 50 brothers and sisters who played particularly vital roles in the grand conspiracy. Some of the many others are listed on the following page. We hope to keep the information up to date. If you have comments, law suits, suggestions or death threats, please send them to: Dear Abbie P.0. Box 213, Cooper Station, New York, NY 10003. Many of the tips might not work in your area, some might be obsolete by the time you get to try them out, and many addresses and phone numbers might be changed. If the reader becomes a participating researcher then we will have achieved our purpose.
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incidence of infection, steal syndrome, and thrombosis is needed to guide sample size calculations in future clinical trials to ensure that they have adequate statistical power. For example, in a systematic review of clinical trials testing the efficacy of blood flow surveillance in reducing risk of access loss, the biggest limitation in current trials was inadequate statistical power to detect a difference between the intervention group and control group among prevalent patients. 76 Third, there is a need for longer and larger cohort studies that reflect the contemporary dialysis population. Although we included large scale national surveillance studies, a major limitation was the absence of patient characteristics for those using a fistula. This limited our ability to compare the effect of patient characteristics on the complication rates of the fistula. Finally, to advance the quality of vascular access information, future studies need to utilize consistent definitions and reporting methods in accordance to accepted published standards. 19,77 This will permit comparison of fistula outcomes across studies to provide better insight on the burden of fistula complications.
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In our series, we were able to discriminate 2 different patterns of CBF and CBV decrease; MTT was decreased (pattern 1) in 1 group and increased (pattern 2) in the other group. We believe that the decrease in the MTT (pattern 1) in these patients reflects a sump effect from the vascular pedicle supplying the shunt and the adjacent normal brain tissue; thus, we hypothesize this pattern to be a functional type of steal (Fig 4). On the other hand, areas of increased MTT with decreased CBF and CBV (pattern 2) may reflect the arterial steal due to indirect collateral connection or areas remote from the nidus where the blood flow is re- routed from the normal brain toward the AVM, resulting in delayed transit time; thus, we believe this to be an ischemic type of steal. Whether the decreased CBF and CBV in our patients with the differences in MTT reflect the viability of
Usually 3 main arterial trunks emerge from the aortic arch (Fig. 2A). The distances between their origins are the same, although the arteries can change their position, arising from a single arterial trunk or very close together. This usual pattern of 3 branches was found in 83 specimens (80.6%). In the remaining specimens (28 specimens — 27.2%) it was possible to distinguish aortic arches where the left common carotid artery branched very close to the brachiocephalic trunk (Fig. 2B). In 11 cases (10.7%), only a single arterial trunk was found for the brachiocephalic trunk and the left common ca- rotid artery (Fig. 2C, 3). In 7 cases (6.8%) the left vertebral artery sprang directly from the aortic arch between the left common carotid and left subcla- vian arteries (Fig. 2D, 4). In one case the right sub- clavian artery originated from the posterior surface of the aorta at the level of the left subclavian ar- tery, while in another case the right subclavian ar- Table 1. Distribution of foetal age and sex