Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/1677-5449.190124
Jornal Vascular Brasileiro
Case Report

Inversão total do fluxo em artéria carótida interna direita em paciente com estenose grave do tronco braquiocefálico

Total reversal of internal carotid blood flow in a patient with severe stenosis of the brachiocephalic trunk

Carlos Eduardo Del Valle; Luiz Fernando Tosi Ferreira; Pedro Henrique Bragato; Sara Lucy de Oliveira; Fernanda de Oliveira Mauro; Walter Junior Boim de Araújo

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Resumo

RESUMO: As estenoses graves e oclusões do tronco braquiocefálico (artéria inominada) são raras, e apresentam uma grande variedade de manifestações clínicas, com alterações relacionadas a isquemia cerebral hemisférica, vertebrobasilar e de membro superior direito. A causa mais comum é a aterosclerose. A ultrassonografia vascular com Doppler pode revelar inversão de fluxo na artéria vertebral direita, hipofluxo na subclávia, e vários tipos de alterações no fluxo da carótida direita, incluindo hipofluxo, inversão parcial do fluxo durante o ciclo cardíaco, e até mesmo inversão completa do fluxo na carótida interna, achado este bastante raro. Os autores descrevem o caso de paciente do sexo feminino, tabagista, com estenose grave do tronco braquiocefálico e crises de lipotimia. Além do roubo de artéria subclávia e do fluxo parcialmente invertido na carótida comum direita, a paciente apresentava exuberante fluxo invertido na carótida interna durante todo o ciclo cardíaco, achado este não encontrado na literatura em tamanha magnitude.

Palavras-chave

tronco braquiocefálico, ultrassonografia Doppler, isquemia encefálica

Abstract

Occlusions and severe stenoses of the innominate artery (brachiocephalic trunk) are rare and present with a wide variety of clinical manifestations, with hemispheric, vertebrobasilar and right upper limb ischemic symptoms. The most common cause is atherosclerosis. Duplex scanning may show right vertebral artery flow reversal, diminished subclavian flow, and several patterns of right carotid flow disturbance, including slow flow, partial flow reversal during the cardiac cycle and even complete reversal of flow in the internal carotid artery, which is a very uncommon finding. Herein, the authors describe the case of a female patient who was a heavy smoker, had severe stenosis of the brachiocephalic trunk, and had episodes of collapse. Besides the subclavian steal and partial flow reversal in the common carotid artery, duplex scanning also showed high-velocity reversed flow in the internal carotid artery during the entire cardiac cycle, a finding that is not reported in the literature at this magnitude.

Keywords

brachiocephalic trunk; ultrasonography, Doppler, duplex; brain ischemia.

References

1 Guedes BF, Valeriano RP, Puglia P Jr, Arantes PR, Conforto AB. Pearls & Oy-sters: symptomatic innominate artery disease. Neurology. 2016;86(12):e128-31. http://dx.doi.org/10.1212/WNL.0000000000002483. PMid:27001994.

2 Deurdulian C, Emmanuel N, Tchelepi H, Grant EG, Malhi H. Beyond the bifurcation: there is more to cerebrovascular ultrasound than internal carotid artery stenosis! Ultrasound Q. 2016;32(3):224-40. http://dx.doi.org/10.1097/RUQ.0000000000000184. PMid:26588099.

3 Rodriguez JD. Brachiocephalic artery disease progression resulting in complex steal phenomena. J Diagn Med Sonogr. 2016;32(3):173-80. http://dx.doi.org/10.1177/8756479316649950.

4 Borne RT, Aghel A, Patel AC, Rogers RK. Innominate steal syndrome: a two patient case report and review. AIMS Med Sci. 2015;2:360-70. http://dx.doi.org/10.3934/medsci.2015.4.360.

5 Esen K, Yilmaz C, Kaya O, Soker G, Gulek B, Sahin DY. Double steal phenomenon secondary to innominate artery occlusion. J Med Ultrason. 2016;43(3):435-8. http://dx.doi.org/10.1007/s10396-016-0713-1. PMid:27107766.

6 Filis K, Toufektzian L, Sigala F, et al. Right subclavian double steal syndrome: a case report. J Med Case Rep. 2008;2(1):392. http://dx.doi.org/10.1186/1752-1947-2-392. PMid:19108708.

7 Han M, Jin BH, Nam HS. The role of duplex sonography in right subclavian double steal syndrome. Korean J Clin Lab Sci. 2017;49(3):316-21. http://dx.doi.org/10.15324/kjcls.2017.49.3.316.

8 Uzun M, Bağcier Ş, Akkan K, Uzun F, Karaosmanoğlu D, Bursali A. Innominate steal phenomenon: color and spectral Doppler sonographic findings. J Ultrasound Med. 2008;27(10):1537-8. http://dx.doi.org/10.7863/jum.2008.27.10.1537. PMid:18809968.

9 Tenny ER, Fleischmann D. The lone carotid: ultrasound findings in rare innominate artery occlusion. J Vascular Ultrasound. 2017;41(4):179-80. http://dx.doi.org/10.1177/154431671704100406.

10 Racy CB Fo. Oclusão do tronco arterial bráquio-cefálico. Rev Angiol Cir Vasc. 2019;2:17-9.

11 Grant EG, El-Saden SM, Madrazo BL, Baker JD, Kliewer MA. Innominate artery occlusive disease: sonographic findings. AJR Am J Roentgenol. 2006;186(2):394-400. http://dx.doi.org/10.2214/AJR.04.1000. PMid:16423944.

12 Brunhölzl CH, von Reutern GM. Hemodynamic effects of innominate artery occlusive disease. Evaluation by Doppler ultrasound. Ultrasound Med Biol. 1989;15(3):201-4. http://dx.doi.org/10.1016/0301-5629(89)90064-1. PMid:2662550.

13 Rawal AR, Bufano C, Saeed O, Khan AA. Double steal phenomenon: emergency department management of recurrent transient. Clin Pract Cases Emerg Med. 2019;3(2):144-8. http://dx.doi.org/10.5811/cpcem.2019.1.40960. PMid:31061972.

14 Grosveld WJ, Lawson JA, Eikelboom BC, vd Windt JM, Ackerstaff RG. Clinical and hemodynamic significance of innominate artery lesions evaluated by ultrasonography and digital angiography. Stroke. 1988;19(8):958-62. http://dx.doi.org/10.1161/01.STR.19.8.958. PMid:3041653.

15 Scoutt LM, Gunabushanam G. Carotid ultrasound. Radiol Clin North Am. 2019;57(3):501-18. http://dx.doi.org/10.1016/j.rcl.2019.01.008. PMid:30928074.

16 Willoughby AD, Kellicut DC, Ching BH, Katras A, Shimabukuro M, Ayubi FS. Double steal syndrome: two case presentations. J Vasc Med Surg. 2014;2:1000143.

17 Ackerstaff RG, Hoeneveld H, Slowikowski JM, Moll FL, Eikelboom BC, Ludwig JW. Ultrasonic duplex scanning in atherosclerotic disease of the innominate, subclavian and vertebral arteries. A comparative study with angiography. Ultrasound Med Biol. 1984;10(4):409-18. http://dx.doi.org/10.1016/0301-5629(84)90195-9. PMid:6390900.

18 Calin A, Rosca M, Beladan C, et al. Unexpected vascular Doppler findings in an asymptomatic patient with marked blood pressure difference between arms. Rom J Cardiol. 2018;28:466-8.

19 Horrow MM, DeMauro CA, Lee JS. Carotid Doppler: low velocity as a sign of significant disease. Ultrasound Q. 2008;24(3):155-60. http://dx.doi.org/10.1097/RUQ.0b013e3181817c3f. PMid:18776788.

20 Maier S, Bajko Z, Motataianu A, et al. Subclavian double steal syndrome presenting with cognitive impairment and dizziness. Rom J Neurol. 2014;13:144-9.

21 Schwend RB, Hambsch K, Baker L, Kwan K, Torruella A, Otis SM. Carotid steal syndrome: a case study. J Neuroimaging. 1995;5(3):195-7. http://dx.doi.org/10.1111/jon199553195. PMid:7626831.

22 Sidhu PS, Morarji Y. Case report: a variant of the subclavian steal syndrome. Demonstration by duplex Doppler imaging. Clin Radiol. 1995;50(6):420-2. http://dx.doi.org/10.1016/S0009-9260(05)83145-9. PMid:7789032.

23 Verlato F, Avruscio GP, Milite D, Salmistraro G, Deriu GP, Signorini GP. Diagnosis of high-grade stenosis of innominate artery. Angiology. 1993;44(11):845-51. http://dx.doi.org/10.1177/000331979304401101. PMid:8239055.

24 Zwiebel WJ, Pellerito JS. Tricky and interesting carotid cases. Ultrasound Q. 2005;21(2):113-22, quiz 151, 153-4. PMid:15905824.

25 Makaloski V, von Deimling C, Mordasini P, et al. Transcarotid approach for retrograde stenting of proximal innominate and common carotid artery stenosis. Ann Vasc Surg. 2017;43:242-8. http://dx.doi.org/10.1016/j.avsg.2017.02.009. PMid:28478176.
 

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