Which patients with subclavian artery stenosis are suitable for conservative treatment? Which are suitable for surgical treatment?

Author: Li Qingle, Chief Physician, Peking University People's Hospital

Reviewer: Chen Zhong, Chief Physician, Beijing Anzhen Hospital, Capital Medical University

According to statistics, among all people, the incidence of unilateral subclavian artery stenosis is about 1%-2%. For people over 70 years old, the incidence of unilateral subclavian artery stenosis is about 7%-9%. Bilateral subclavian artery stenosis is relatively rare and accounts for a lower proportion.

Once subclavian artery stenosis is diagnosed, treatment should be initiated actively.

The first is basic treatment, that is, drug treatment. If the condition is not very serious and the symptoms are mild, the basic direction of drug treatment is to improve collateral circulation and treat the underlying disease, including the three highs, because high blood pressure, high blood sugar, and hyperlipidemia can cause the development of atherosclerotic plaques. In addition, we need to change bad living habits, including irregular diet, staying up late, alcoholism, smoking, etc. Bad living habits must be eradicated, which is also a basic treatment.

If the lesion is already very severe and upper limb weakness occurs, including blood steal, simple drug treatment or basic treatment may not be enough at this time, and surgical intervention is required.

Surgical intervention is now divided into two categories. One is the classic surgical revascularization, including bypass surgery. If the subclavian artery is blocked, you can bypass it from the opposite side, or you can do a carotid-subclavian artery or axillary artery bypass surgery on the same side. The most classic is the axillary artery-axillary artery bypass.

If one side is blocked but the other side is not, a small incision is made below the clavicle. There is an axillary artery on this side and an axillary artery on the other side. Then the autologous great saphenous vein is taken, or an artificial blood vessel is used, to perform a bypass from one end to the other, that is, from lumen to lumen, with a tube connecting the middle. This is an extra-anatomical bypass, which causes less damage. If the bypass is performed through an open chest or from the aortic arch, the damage will be greater, so it is better to perform a bypass outside the anatomy. This is a surgical procedure.

Figure 1 Original copyright image, no permission to reprint

There are also some other surgical procedures, including bypassing the blood flow from the carotid artery to the subclavian artery. Some people may consider that the blood flow from the carotid artery is "borrowed" and will affect the brain circulation, so they are used relatively less, but in fact it will not affect the blood supply to the carotid artery.

In recent years, due to the development of interventional technology, we can achieve more minimally invasive treatment, that is, use a catheter and guidewire to pass through the occluded lesion, and then use a balloon to expand it. This is the same way as putting a stent in the heart to solve coronary heart disease to solve the lesions of the subclavian artery. This is also possible.

In clinical practice, for some asymptomatic patients, even if stenosis is seen on imaging, conservative treatment is recommended first, because any surgical intervention may cause restenosis and may also cause other problems and complications. Therefore, for asymptomatic patients, it is generally recommended to try conservative treatment for 3-6 months to see if there is any progress.

In fact, from the perspective of imaging, if the stenosis is less than 50%, conservative treatment is generally recommended first. For example, collateral circulation can be improved. In addition to aspirin, there are also cilostazol, beraprost sodium, and some Chinese patent medicine ingredients, which can improve collateral circulation. These are some common clinical drugs. Another thing is to control the primary disease, including controlling the risk factors of arteriosclerosis, such as lowering blood pressure, blood sugar, blood lipids, including quitting smoking, etc. This is a basic treatment.

If the stenosis exceeds 50% but there are no symptoms, conservative treatment and observation can be continued, with a check-up every 3 months or so to see how the plaque develops.

If conservative treatment is ineffective and the plaque continues to develop, from a 50% stenosis to more than 70%, the hemodynamics will also change, including blood steal, and the patient may experience symptoms, such as ischemic symptoms, upper limb weakness, numbness, and coldness, as well as symptoms of posterior vertebral artery blood steal, dizziness, and unstable standing. At this time, conservative treatment may be ineffective, and we still recommend surgical intervention to improve ischemia, revascularization, and avoid further development of the disease.

Figure 2 Original copyright image, no permission to reprint