| Abstract | Subclavian steal syndrome ili u prijevodu sindrom krađe krvi potključne arterije je fenomen koji se događa uslijed stenoze ili okluzije potključne arterije koja je rezultat ateroskleroze. Sindrom uključuje specifičan retrogradni tok krvi vertebralne arterije koja pokušava osigurati potrebe gornjeg ekstremiteta zbog čega krade krv cerebralnoj cirkulaciji. Osim aterosklezore uzroci mogu biti Takayasu arteritis,arteritis divovskih stanica,kongenitalne anomalije velikih krvnih žila,kirurški zahvati te sindrom kompresije toraksa. Rizični čimbenici su: pušenje,hiperkolesterolemija,diabetes melitus,hipertenzija i hiperhomocisteinemija.Prevalencija pojave sindroma krađe krvi potključne arterije iznosi 0.6-6.4% i zahvaća u većini slučajeva lijevu potključnu arteriju. Pojavljuje se u odrasloj dobi nakon 50e godine života i to češće u muškaraca nego u žena u omjeru 2:1. Klasifikacija sindroma se određuje prema područjima iz kojih je krv ukradena (vertebralno-vertebralna, karotidno-bazilarna, vanjsko karotidno-bazilarna i karotidno-potključna) te prema težini hemodinamskih poremećaja (presubklavijski sindrom krađe krvi, intermitentna i stalna). Pacijenti su najčešće asimptomatski dok kod onih koji razviju simptome, sindrom je otkriven slučajno. U simptome koji su izazvani ishemijom ruke spadaju: bol ruke, umor, hladnoća, parestezija,utrnulost,klaudikacije. I nestabilna angina pectoris može biti simptom sindroma krađe krvi potključne arterije pogotovo ako je kao premosnica korištena unutarnja mamarna arterija. Takva krađa krvi od miokarda zbog potključne stenoze se naziva koronarna krađa krvi potključne arterije (CSSS). Neurološki simptomi koji mogu biti izazvani ishemijom moždanog debla su: vrtoglavica,nesvjestica, ataksija, epileptični napadaji, diplopija, nistagmus, zamućenje vida, hemianopsija, sinkopa,tinitus,gubitak sluha,bilateralna brahijalna diplegija. Fizikalnim pregledom možemo utvrditi: razliku u brahijalnim sistoličkim tlakovima obje ruke,smanjenje amplitude pulsa ili njegovo odsustvo,šumove vertebralne i potključne arterije, promjenu na koži ruku i noktiju u obliku promjene boje, krvarenja, ulceracije. Za konačnu potvrdu dijagnoze koriste se neinvazivne metode u dijagnostici te u njih ubrajamo: Doppler, duplex ultrasonografiju, transkranijalni doppler, magnetsku rezonancu, MR angiografiju, CT angiografiju. Najčešće se koristi Doppler, dok je najbolja metoda CT angiografija zbog visoke rezolucije,specifičnosti i mogućnosti vizualizacije struktura. Sekundarnom prevencijom rizičnih faktora smanjuje se i pojavnost sindroma. Bolesnici koji boluju od sindroma ali nemaju simtopme, također i oni poslije zahvata moraju uzimati medikamentoznu terapiju antitrombocitnih i antikoagulantnih lijekova (aspirin,klopidogrel) .Postoji endovaskularna (angioplastika i stent) i kirurška (bypass) tehnika. Mnogo čimbenika ovisi za koju se odlučiti. Kod manjih stenoza svakako se preporučuje endovaskularni pristup zbog manje hospitalizacije i bržeg oporavka. Takvi bolesnici su na doživotnoj terapiji apsirinom, mada i dalje zlatni standard revaskularizacije predstavlja bypass tehnika. Koja ima odlične rezultate,nisku stopu smrtnosti i mali postotak restenoza za razliku od endovaskularne tehnike. |
| Abstract (english) | "Subclavian steal syndrome" or in translation Subclavian steal syndrome is a phenomenon that occurs due to stenosis or occlusion of the subclavian artery as a result of atherosclerosis. The syndrome includes specific retrograde blood flow in the vertebral artery, which tries to ensure the needs of the upper extremities for which "steals" blood cerebral circulation. Except atherosclerosis, the other causes of Subclavian steal syndrome are: Takayasu arteritis, giant cell arteritis, congenital anomalies of large blood vessels, surgery syndrome and compression of the thorax. Risk factors are: smoking, hypercholesterolemia, diabetes mellitus, hypertension and homocysteinemia. Prevalence appearance of subclavian steal syndrome is 0.6-6.4% and affects in most cases left subclavian arteries. It occurs in adulthood after 50s and more often in men than in women in the ratio 2: 1. Classification syndrome is determined by the areas from which blood was "stolen" (vertebral-vertebral, carotid-basilar, external carotid-basilar and carotid-subclavicular) and the severity of hemodynamic disturbances (pre-subclavian steal syndrome, intermittent and continuous). Patients are usually asymptomatic while in those who develop symptoms, the syndrome was discovered by accident.The symptoms caused by ischemia of upper extremity include: pain hands, fatigue, coldness, paresthesia, numbness, claudication. And unstable angina pectoris may be a symptom of subclavian steal syndrome ,especially if used as a bypass ; internal mammary artery. Such stealing blood from the myocardium because of subclavian stenosis is called coronary subclavian steal syndrome (CSSS).Neurological symptoms that may be caused by ischemia of the brain stem are: dizziness, fainting, ataxia, seizures, diplopia, nystagmus, blurred vision, hemianopia, syncope, tinnitus, hearing loss, bilateral brachial diplegia. Physical examination can determine: the difference in brachial systolic pressures both hands, reducing the amplitude of the pulse, or its absence, murmure of vertebral and subclavian arteries, a change in the skin of hands and nails in the form of discoloration, bleeding, ulceration.For final confirmation of diagnosis used non-invasive methods and they include: Doppler, duplex ultrasonography, transcranial Doppler, MRI, MR angiography, CT angiography. The most commonly used is Doppler, while the best method is CT angiography because of high resolution, specificity and visualization of structure.Secondary prevention of risk factors reduces the incidence of the syndrome. Patients with the syndrome who does not have simptoms, and they after the procedure must take drug treatment antiplatelet and anticoagulant drugs (aspirin, clopidogrel).There are endovascular (angioplasty and stents) and surgery (bypass) technique. Many factors depends on surgeons to decide. For smaller stenosis definitely recommended endovascular due to less hospitalization and faster recovery. Such patients are at lifelong therapy with aspirin, but still the gold standard represents revascularization bypass techniques. Which has excellent results, low death rate and low percentage restenosis unlike endovascular techniques. |
