锁骨下动脉窃血综合征详解VIP免费

Bonegroup2012.6.7HistoryMale，62yearsoldAtransientsyncopeSphygmus：72times/min，left--weakBloodpressure：rightarm—110/70mmHgleftarm—70/50mmHgPossiblediagnosis？Why？FinaldiagnosisImageimpression：Subclavianarterywallcalcification,stenosis；thrombosiscannotbeexcludedClinicaldiagnosis：SubclavianStealSyndrome(SSS)SubclavianStealSyndromeDefinition：Subclavianstealsyndromeistheproximalsubclavianarteryorinnominatearteryobstruction（causedbyavarietyofreasons），Subclavianarterydistalintraluminalpressuredecreased，ipsilateralbloodpressurebelowthevertebral–basilararterialpressure---syphonage，soresultinSSSClinicalmanifestationsupperlimbsymptom：Somepatientscomplainedofweakness,numbnessandpainwhentheupperlimbsexerciseVertebrobasilarinsuficiencysymptom：Syncope,dizziness,vertigo,standinginstabilityandoccipitalpainisthemostcommoncomplaintcarotidarteryinsufficiencysymptom：rarely，butcanoccurinthepatientofinnominatearteryobstructionPhysicalfindingsIpsilateralradialarterypulseweakenedordisappeared,bilateralpulsenonsynchronization(delay0.03~0.06s）Pressuredifferential(PD)>20mmHg（contralateral>Ipsilateral）（Only16%ofthepatientswithaPD20mmHgdidnothaveSSS.ThisresultsuggeststhatarmBPdifferential20mmHgishighlycorrelatedwiththepresenceofSSS）PhysicalfindingsTheipsilateralsupraclavicularfossavascularbruit(systolic)Javidtest：positive(aftertheoppressionofthecommoncarotidartery,radialarterypulseweakened)PathogenyArteriosclerosis（mostcommon）Congenitalmalformations(aorticstenosis,subclavianarterydistalatresia)Takayasuarteritis(tuberculosis,syphiliticaortitis)TumorcompressionRadiotherapySSSbloodpathway（一）VA－VAcontralateralvertebralartery↓vertebrobasilararteryconfluence↓ipsilateralvertebralartery↓ipsilateralsubclavianarterydistalSSSbloodpathway（二）BA－VAbasilarartery↓ipsilateralvertebralartery↓ipsilateralsubclavianarterydistalSSSbloodpathway（三）PCA－BA－VAposteriorcerebralartery↓basilarartery↓ipsilateralvertebralartery↓ipsilateralsubclavianarterydistalSSSbloodpathway（四）OA－VAexternalcarotidarterybranchoccipitalartery↓occipitalarteryandvertebralarteryanastomoticbranch↓vertebralartery↓subclavianarterydistalDiagnosticmethods（一）Dopplerultrasoundexamination※Observethebloodflow※VertebralarteryappearingreversespectrumisthetypicalperformanceofSSSA,Normalflowinapatientwithoutsubclavianstealsyndrome(SSS).Ithasalowwavepatternresistancewithcephaladflowthroughoutthecardiaccycle.B,FlowvelocitywaveformintheleftvertebralarteryindicatingapartialSSS.Theflowduringsystoleandthebeginningofdiastoleisreversed.Therewasa25mmHgPD.C,CompletestealinapatientwitharmbloodPDof60mmHg.Theflowinthevertebralarteryisreversedthroughoutthecardiaccycle.TheseveritycanbegradedbasedonthevertebralDopplerspectralpatterns:I：antegradeflowwithdiminishedpeaksystolicvelocityII：alternatingflow—antegradeflowinthediastolicphaseandretrogradeflowinthesystolicphaseIII：completelyretrogradeflowDiagnosticmethods（二）DigitalSubtractionAngiography—DSA※DSA---thegoldstandardstodiagnoseSSSthedegreeofSubclavianarterystenosisthelocationofsubclavinaarterytheprogressoftherefluxbloodflow（thecontralateralvertebralartery→theipsilateralvertebralartery→theipsilateralsubclavianarterydistal）※limitionexpensive,invasive，difficulttorepeatsensitivetocompletedstenosis，bu...