A 68-year-old man with hypertension, dyslipidemia, and diabetes mellitus presented with dizziness, presyncope, and blurring of vision that occurred when he used his left hand while gardening. He reported no history of coronary or vascular disease.
A physical examination was notable for blood pressures of 150/70 mm Hg in the right arm and 80/60 mm Hg in the left arm, with weak brachial and radial pulses on the left side. The cardiac examination revealed an audible S4, a bruit in the right carotid artery, and a thrill and bruit over the left subclavian artery.
Angiography showed a severe proximal left subclavian stenosis (arrow), with retrograde flow in the left vertebral artery. This pattern of flow, and the resulting clinical symptoms, is known as the subclavian steal syndrome.
The patient underwent successful stenting of the subclavian stenosis. He began receiving medical therapy for his peripheral vascular disease, consisting of aspirin, a high-dose statin, and an angiotensin converting enzyme inhibitor (ACEI). At a follow-up visit 3 months later, there was clinically significant improvement in symptoms, including a difference of 15 mm Hg in systolic blood pressure between the two arms and no subclavian bruit.