Angiographic visualization of high-flow arteriovenous fistula-induced subclavian steal syndrome
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IMAGES IN CARDIOVASCULAR INTERVENTION
Angiographic visualization of high‑flow arteriovenous fistula‑induced subclavian steal syndrome Daisuke Miyawaki1 · Tetsuya Nomura1 · Hiroshi Kubota1 · Naotoshi Wada1 · Natsuya Keira1 · Tetsuya Tatsumi1 Received: 6 August 2020 / Accepted: 9 September 2020 © Japanese Association of Cardiovascular Intervention and Therapeutics 2020
An 86-year-old man who had been undergoing intermittent chronic hemodialysis for 3 years was admitted to our hospital for further examination of recurrent syncope. Vascular ultrasound showed reversed blood flow in the left vertebral artery ipsilateral with an arteriovenous fistula (AVF) (Fig. 1a). Angiography demonstrated no stenosis in the proximal left subclavian artery (Fig. 1b), and favorable blood flow in the left brachial artery drained to the cephalic vein via AVF around the cubital fossa (Fig. 1c). Control angiography from the right vertebral artery showed reversed blood flow in the left vertebral artery via the vertebral–basilar system (Fig. 1d). Antegrade blood flow was not observed in the left vertebral artery (Fig. 1e). Manual compression of AVF changed the blood flow antegradely in the left vertebral
artery (Fig. 1f, g). The flow volume in the brachial artery was reduced from around 1000 to 600 mL/min by ligating the venous side of AVF. Thereafter, reversed blood flow in the left vertebral artery has changed to antegrade one (Fig. 1h), and the symptom of syncope has not recurred ever after. A previous study involving vascular Doppler examination in patients with AVF reported that completely reversed flow in the vertebral artery was observed in only 1 out of 335 patients [1]. This image suggests the importance of awareness of high-flow AVF as the potential cause of subclavian steal syndrome and syncope in hemodialysis patients.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12928-020-00709-8) contains supplementary material, which is available to authorized users. * Tetsuya Nomura [email protected] 1
Department of Cardiovascular Medicine, Kyoto Chubu Medical Center, 25, Yagi‑Ueno, Yagi‑cho, Nantan, Kyoto 629‑0197, Japan
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Angiographic visualization of high‑flow arteriovenous fistula‑induced subclavian steal… ◂Fig. 1 a Vascular ultrasound showing reversed blood flow in the left
vertebral artery. Angiography showing no stenosis in the proximal left subclavian artery (b), and high-flow AVF from the brachial artery to cephalic vein (c, arrowheads). d Digital subtraction angiography showing reversed blood flow in the left vertebral artery via vertebral–basilar system. Arrows indicate the direction of blood flow. e No antegrade blood flow in the left vertebral artery. f Manual compression of AVF causing disappearance of the reversed blood flow in the left vertebral artery. g Recovered antegrade blood flow in the left vertebral artery by AVF compression. The arrow indicates the direction of blood flow. h Normalized blood flow in the
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