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Takayasu arteritis(TA) is a rare cause of subclavian steal syndrome(SSS), and it is often ignored in the diagnosis of SSS. This article presents a case of left subclavian steal syndrome caused by TA and review the diagnosis and treatment strategy.
A 40-year-old middle-aged male patient was admitted to our hospital because of progressing dizziness for more than 3 weeks, and numbness in the left finger for 1 week, with a history of hypertension for 1 year peaked at 160/95mmHg, and now is well controlled by medicine. Besides, He had smoked for nearly 20 years, 30 cigarettes a day. Physical examination showed right upper limb blood pressure 148/86mmHg, left upper limb blood pressure 100/70mmHg. Other systems were normal. Ultrasonography (USG) showed reverse blood flow in the left subclavian artery, plaque formation of the left subclavian artery (16.0mm×4.7mm), and the blood flow of the left upper limb artery was significantly lower than that of the right upper limb artery. Echocardiography revealed widened aorta and thickened interventricular septum, EF 79.1%. Contrast enhanced magnetic resonance angiography (CEMRA) showed local stenosis in the left subclavian artery proximal to the posterior part of the joint, about 8mm longitudinal length. The left vertebral artery was not developed in the neck MRA(TOF), but could be seen to develop in CEMRA, which was thinner than the contralateral side, suggesting that regional blood flow was slow. Laboratory tests suggest anti neutrophil cytoplasmic antibodies (ANCA) directed to proteinase 3 (PR3) and myeloperoxidase (MPO) were positive. Other autoimmune index were negative. Accordingly, it is considered that the left SSS may cause by TA.
Percutaneous angiography(PTA) was performed for guidance of further treatment, which revealed that the left subclavian artery was stenosis about 95% near the beginning, and no stenosis in the distal segment coronary artery, renal artery, internal carotid artery and the right subclavian artery was found. Then a stent PRECISE*30mm was implanted in the left subclavian artery. Stenosis was disappeared and blood flow was unobstructed after operation. After the above treatment, the symptoms of the patient were significantly improved, and USG showed no obvious abnormalities in the blood vessels of the neck and upper extremities.
TA is a systemic autoimmune disease, often involving the blood vessels, resulting in a narrow range of blood vessels and cause a series of clinical manifestations. It occurs in the anterior part of the subclavian artery, which can cause local vascular stenosis, vertebral artery blood flow occlusion and the compensation from the basilar artery, leads to the reverse flow of the vertebral artery, which is known as SSS. The diagnosis of TA is mainly based on the clinical and hematological examination, and the vascular complications were diagnosed by USG or MRA. Angiography can be used in diagnosis and intervention treatment. We aim to emphasize the vital importance of experience that clinicians should pay more attention to search for the primary disease of SSS. Appropriate treatment options depend on early accurate diagnosis, and treatments of primary disease are as important as intervention for local vascular lesions. So far, besides systemic treatment by corticosteroid of TA, peripheral vascular stenosis is mainly treated by surgery or interventional therapy, such as balloon dilatation or stent implantation.