Clinician Update
Subclavian Steal Syndrome
Brian J. Potter, MD, MSc; Duane S. Pinto, MD, MPH
Case Presentation
A 90-year-old woman who under-
went coronary artery bypass graft
surgery 15 years ago was brought to
the Emergency Department from her
assisted living facility after developing
chest pain, dyspnea, and diaphoresis.
On arrival, she continued to have chest
pain and exhibited signs of conges-
tive heart failure. Her ECG revealed
2-mm ST-segment depressions across
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the precordium associated with 2-mm
ST-elevations in aVR (Figure 1).
Given this clinical picture, she was
urgently brought to the cardiac cath-
eterization laboratory, where angiog-
raphy revealed totally occluded native
coronaries and an occluded saphenous
vein graft to an obtuse marginal artery.
The saphenous vein graft to the right
coronary circulation was patent as
was the left internal mammary artery
(IMA) bypass to the left anterior
descending artery. However, there was
a severe (99%) left subclavian artery
stenosis (Movie I in the online-only
Data Supplement). Stenting of the left
subclavian artery resulted in the reso-
lution of the patient’s chest pain and
electrocardiographic abnormalities. She
was discharged to home 9 days later.
From the Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.113.
006653/-/DC1.
Correspondence to Duane S. Pinto, MD, MPH, Beth Israel Deaconess Medical Center, Interventional Cardiology, 185 Pilgrim Road, Baker 4, Boston,
MA 02215-5324. E-mail dpinto@bidmc.harvard.edu
(Circulation. 2014;129:2320-2323.)
© 2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
Overview
“Subclavian steal” refers to a phenom-
enon of flow reversal in a branch of
the subclavian artery that is the result
of an ipsilateral hemodynamically
significant lesion of the proximal sub-
clavian artery.1,2 Subclavian stenoses,
however, are most often asymptomatic
and therefore do not require specific
therapy other than that directed at the
underlying etiology. “Subclavian steal
syndrome” can become manifest in
some patients with symptoms of arte-
rial insufficiency afflicting the brain,1–3
the upper extremity,2 or even the heart
if part of the coronary circulation is
supplied via an IMA graft,4 as was the
case in this patient.
Pathophysiology of
Subclavian Steal
A subclavian steal syndrome may occur
when a significant stenosis in the sub-
clavian artery compromises distal per-
fusion to the IMA, vertebral artery, or
axillary artery. As the degree of subcla-
vian stenosis progresses, the pressure
distal to the stenosis will eventually
fall below the pressure transmitted by
the contralateral (noncompromised)
vertebral artery via the basilar artery or
DOI: 10.1161/CIRCULATIONAHA.113.006653
2320
by the carotid artery through the Circle
of Willis and basilar artery (Figure 2).
The result is a pressure gradient favor-
ing reversed blood flow (retrograde
flow) in the vertebral artery distal and
ipsilateral to the subclavian stenosis.1
Atherosclerosis is the most com-
mon cause of subclavian stenosis and,
thus, steal syndromes, irrespective of
the clinical manifestation.2,5,6 However,
large artery vasculitis, thoracic outlet
syndrome, and stenosis after surgical
repair of aortic coarctation or tetralogy
of Fallot (with a Blalock-Taussig shunt)
are other possible causes. Congenital
abnormalities, such as a right-sided aor-
tic arch with an isolated left subclavian
artery, can also lead to subclavian nar-
rowing and steal syndromes and should
be considered, particularly if a steal syn-
drome develops in a younger patient.
When the proximal subclavian ste-
nosis is at least moderate (>50%),
>90% of patients will have either inter-
mittent or continuous flow reversal in
the vertebral artery,7 though not all will
be symptomatic. Duplex ultrasonogra-
phy and transcranial Doppler appears
more sensitive than conventional angi-
ography for detecting flow reversal. In
the majority of patients, a subclavian

Figure 1. Presenting ECG of the 90-year-old woman in the clinical vignette demonstrating extensive ischemia (ST-depressions) and
ST-elevation in aVR.
stenosis with or without flow rever-
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sal in the ipsilateral vertebral artery
is asymptomatic. However, patients
with flow reversal can become symp-
tomatic if collateral blood supply from
the vertebrobasilar circulation cannot
accommodate increased demand, such
as during exercise or in the setting of
an arteriovenous fistula.
In the minority of patients who
manifest symptoms related to subcla-
vian stenosis, arm claudication is the
most common complaint, consisting of
exercise-induced arm pain or fatigue.
Occasionally, coolness or paresthesias
in the extremity may be noted at rest
or with exertion. Unilateral reversal of
vertebral flow may cause vertebrobasi-
lar transient ischemic attacks in rare
circumstances. Upper extremity exer-
cise, by reducing arterial resistance,
increases blood flow to the arm and
can precipitate lateralizing symptoms
of vertebrobasilar insufficiency among
persons without sufficient collateral
flow.1,3 Similarly, a steal phenomenon
may also occur in dialysis patients with
an ipsilateral arteriovenous fistula. It
should also be noted that bilateral ver-
tebral flow reversal has been associated
with nonlateralizing cerebral ischemia.
Potter and Pinto   Subclavian Steal Syndrome   2321
Vertebrobasilar insufficiency pres-
ents classically as “drop attacks,” but
may also manifest as dizziness, dip-
lopia, nystagmus, tinnitus, or even
hearing loss.1,3 However, even when
flow reversal in the vertebral system
is observed, ischemic neurological
events may be attributable to other pro-
cesses, such as thromboembolism or
embolization of atherosclerotic mate-
rial from proximal subclavian disease,
and is not necessarily related to a steal
phenomenon.
Finally, a coronary-subclavian steal
phenomenon4 may occur in patients
who have undergone coronary artery
bypass graft if a stenosis occurs in the
subclavian artery proximal to the take-
off of an IMA graft utilized to perfuse
the heart. If arterial flow demand is
increased in another vascular bed, as
with ipsilateral upper extremity exer-
cise, a share of the coronary circulation
may be “stolen”, leading to angina or
even infarction.
Diagnosis
Subclavian stenosis should be sus-
pected in any patient with vertebrobas-
ilar territory neurological symptoms,
arm claudication, or coronary ischemia
where the IMA has been used for
coronary artery bypass graft surgery.
Physical examination findings sug-
gestive of subclavian stenosis include
a discrepancy of >15 mm Hg in blood
pressure readings taken in both upper
extremities, delayed or decreased
amplitude pulses in the affected side,
and a bruit in the supraclavicular
fossa.2,8–10 A bruit in the suboccipital
area may also be heard. The skin and
nails of the affected side should be
examined to rule out atrophic changes
attributable to arterial insufficiency. A
finding of diminished pulses at multi-
ple sites suggests Takayasu’s arteritis.11
A variety of noninvasive imaging
modalities can be selectively used to
diagnose subclavian stenosis when
a steal phenomenon is suspected.
Continuous wave Doppler and duplex
ultrasonography are readily accessible,
inexpensive, and accurate when per-
formed by an experienced operator.12
Transcranial Doppler may be more use-
ful in the setting of neurological symp-
toms. Magnetic resonance angiography
and computed tomography angiogra-
phy are also alternatives, but are per-
haps best used to quantify the degree
of subclavian artery stenosis when
 2322  Circulation  June 3, 2014
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Figure 2. Schematic drawing of the circulation involved in subclavian steal phenomena
and the flow adaptation in response to a proximal subclavian stenosis.
Doppler techniques are inconclusive,
if the etiology of subclavian stenosis
is uncertain, or for planning interven-
tions. Magnetic resonance angiography
offers comparable resolution to com-
puted tomography angiography, but,
for reasons of cost and availability, is
used most commonly when computed
tomography angiography is contraindi-
cated or indeterminate.
Management
Even asymptomatic subclavian artery
stenosis is associated with increased risk
of morbidity and mortality related to
underlying atherosclerotic disease bur-
den in other vascular beds.5,6,9 The pres-
ence of subclavian stenosis is associated
with increased total mortality (hazard
ratio, 1.40) and cardiovascular disease
mortality (hazard ratio, 1.57)5 and with
an increased risk of cerebrovascular
ischemic events related to progressive
carotid stenosis and compromised col-
lateral pathways. Thus, subclavian ste-
nosis is a marker of cardiovascular risk
and identifies a population that will
benefit from aggressive secondary pre-
vention. Medical therapy that includes
aspirin, β-blockade, angiotensin con-
verting enzyme inhibition, and a statin
reduces long-term mortality in lower
extremity peripheral artery disease.13
Such a regimen is recommended for
patients with subclavian stenosis.
Incidental subclavian stenosis, in the
absence of symptoms, rarely requires
revascularization therapy, even if flow
reversal is demonstrated. The lone
exception is among patients in whom
coronary artery bypass graft with an
ipsilateral IMA graft is planned. Here,
pre-emptive treatment of the subcla-
vian stenosis is recommended.8
For patients with mild symptoms, med-
ical therapy and observation are appropri-
ate, because symptomatic improvement
without intervention has been described.
Patients with burdensome symptoms
and proximal subclavian artery occlu-
sive disease can be successfully treated
either surgically or percutaneously.8,14–20
Balloon angioplasty and stenting can
be performed when stenting is unlikely
to compromise the vertebral circula-
tion. Technical success of the percutane-
ous approach can be achieved in >90%,
with 5-year patency rates of 85%.20
Continuous flow reversal appears to be
a marker for a higher risk of restenosis
compared with those with intermittent
flow reversal at baseline.17 Ultimately, up
to 10% of patients will have symptomatic
restenosis, 95% of whom can be man-
aged by repeat endovascular therapy.16
Longer or more distal occlusions
may be better addressed surgically.
Surgical revascularization consists of
bypass in the form of carotid-subclavian
bypass, carotid transposition, or axillo-
axillary bypass surgeries that, overall,
have patency rates in excess of 70%
at 5 years. However, the success rate
is >80% if the common carotid is used
in the bypass. Axillo-axillary bypass,
by contrast, has significantly lower
patency rates (46%)18 and is therefore
typically reserved for patients with
elevated perioperative risk. Patients in
whom central nervous symptoms pre-
dominate should have carotid stenoses
addressed before any attempt at surgi-
cal revascularization of the subclavian
system. Neurological symptoms abate
after re-establishment of normal carotid
anterograde flow, even in the setting of
significant subclavian lesions. No pro-
spective randomized comparisons of
percutaneous and surgical revascular-
ization for subclavian stenoses exist.15
Patients with both prohibitive surgical
risk and unfavorable anatomy for per-
cutaneous treatment can be managed
with antiplatelet therapy and general
cardiovascular prevention strategies.
Summary
“Subclavian steal” refers to a syn-
drome of symptoms relating to arterial

insufficiency in a branch of the subcla-
vian artery stemming from flow rever-
sal, attributable to occlusive disease in
the subclavian artery proximal to that
branch that is usually atherosclerotic
in cause. Most patients are asymp-
tomatic, but patients with IMA bypass
grafts may manifest angina elicited by
exercise of the upper extremity ipsi-
lateral to the graft and stenosis (so-
called “coronary-subclavian steal”).
Subclavian steal may also manifest
as vertebrobasilar insufficiency or,
most commonly, arm claudication.
Subclavian steal should be considered
among patients exhibiting suggestive
symptoms. A meticulous examination
of segmental pulses and pressures,
as well as judicious use of duplex
ultrasonography, magnetic resonance
angiography, computed tomography
angiography, or conventional angi-
ography can confirm the presence of
subclavian stenosis. Symptomatic
patients benefit from either percuta-
neous or surgical revascularization,
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depending on both anatomic and
patient factors. Subclavian stenosis,
regardless of symptoms, is a marker of
atherosclerotic disease and increased
risk for cardiovascular and cerebro-
vascular events.
Acknowledgments
We acknowledge the digital media help
of Serge Korjian in the development of
Figure 2.
Disclosures
None.
Potter and Pinto   Subclavian Steal Syndrome   2323
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Key Words: subclavian artery stenosis ◼ sub­
clavian steal