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Abstract

Objective

To explore the prevalence and risk factors of carotid artery (CA) stenosis among subclavian steal syndrome (SSS) patients and to record their prognoses.

Methods

This observational study was retrospective. From January 2015 to October 2022, 169 patients were diagnosed with SSS. Among them, 51 combined with CA stenosis have surgical indications for both diseases. In this cohort, 24 were treated for subclavian artery (23 endovascular, 1 open), 12 for CA (6 endovascular, 6 open), and 5 for both (1 endovascular, 1 open, 3 hybrid). The primary end point was mortality, and the secondary end points were vessel re-stenosis and other complications. Patients were followed up through outpatient, online, or telephone.

Results

Compared with simple SSS, patients who suffered from both were older (60.51 ± 9.304 versus 66.69 ± 7.921, P < 0.001) and more males (57.6% versus 86.3%, P < .001). Besides, they presented a higher prevalence of hyperhomocysteinemia (P = .015), diabetes mellitus (P = .036), and CVA/TIA (P = .036). No patient died within 30 days after surgery; four complications occurred (1 stroke, 1 hearing loss, 1 TIA, 1 infection). During a median follow-up of 37.6 months, two patients died without relation to the operation, three appeared in-stent restenosis, and one developed contrast nephropathy.

Discussion

This study observed and analyzed different intervention methods and their prognosis in SSS combined with CA stenosis patients, and due to the limited number of participants, more data support would be needed.

Conclusions

The management of SSS patients combined with CA stenosis is more challenging compared to simple SSS. Our research demonstrated different surgical methods and their prognosis.

Keywords

Subclavian steal syndrome carotid stenosis risk factors therapy prognosis

Introduction

Subclavian steal syndrome (SSS) was first described in 1960 with physical signs of an untouchable radial pulse and retrograde blood flow, which is a phenomenon caused by partial or complete occlusion of the proximal segment of subclavian artery or the brachiocephalic trunk.^1–3 In most cases, patients are asymptomatic (accounting for approximately 94.7%) and present as a difference of systolic arterial pressures between both upper limbs of more than 20 mmHg.^4,5 According to the 2011 AHA/ACC guidelines on extracranial carotid and vertebral artery disease, symptomatic patients should be considered for revascularization, which occupied about 5%.^6–10 At present, common treatment methods include carotid-subclavian bypass (CST), axillo-axillary bypass, and percutaneous transluminal angioplasty stenting.^5,11,12

Carotid artery stenosis is a kind of atherosclerotic disease, with a prevalence of 7% in women and 9% in men, and people aged more than 70 years have a significantly higher rate for moderate stenosis (4.8% versus 12.5% in men and 2.2% versus 6.9% in women).^13–15 Besides age and male sex, current drinking of alcohol, diabetes, and high levels of LDL-C can also act as a risk factor for carotid artery stenosis.¹⁶ The main operation includes carotid artery stents (CAS) and carotid endarterectomy (CEA).^10,17,18

In general, for the cerebral arterial system, SSS and carotid artery stenosis are more likely to affect posterior and anterior circulation, respectively, and thus people with both diseases need attention. In 2017, Aketa et al. first reported a patient presenting SSS with bilateral carotid stenosis after receiving right axillary artery-bilateral femoral artery anastomosis, who was treated with PTA and stent replacement.¹⁹ Later in 2021, Song et al. reported another case of unilateral SSS with bilateral carotid artery stenosis and received CEA and SCA angioplasty.⁶

In this article, we focused on patients diagnosed with SSS, aiming to analyze the incidence and risk factors for combing carotid artery stenosis, trying to observe different treatment options and their related prognoses.

Materials and methods

Patient selection, demographic data, and preoperative examination

From January 2015 to October 2022, 169 SSS patients diagnosed in the Vascular Surgery of Peking Union Medicinal College Hospital (PUMCH) were consecutively enrolled in this single-center retrospective observational study. The study was conducted in accordance with the Helsinki Declaration of 1975 as revised in 2013 and all patient details have been de-identified. This study has been approved by the Ethics Review Committee of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences (Ethics Approval Number: I-22PJ721, Date: 2022-11-10) and the reporting of this study conforms to STROBE guidelines.²⁰ Diagnosis mainly relies on the reversal of flow in a vertebral artery (identified by Doppler ultrasonography) and excludes the coronary ischemic form. Among them, we identified 64 patients with common carotid artery (CCA) or internal carotid artery (ICA) stenosis of more than 50% on the basis of CTA. Then, we excluded patients without surgical indications for either SSS or carotid artery stenosis, following the “Guideline on the Management of Patients with Extracranial Carotid and Vertebral Artery,” which is specifically defined as follows.¹⁰ For SSS, we defined it as symptomatic SSS with vertebrobasilar insufficiency or upper extremity symptoms and asymptomatic SSS with severe subclavian artery stenosis (>70%) or occlusion in the affected side. For carotid artery stenosis, it was defined as symptomatic (cerebral ischemia occurring in recent 6 months (TIA or stroke) attributed to the affected carotid artery) carotid stenosis of >50% or asymptomatic carotid stenosis of >70% (North American Symptomatic Carotid Endarterectomy Trial, NASCET). Among the rest 51 patients, 5 only received angiography (3 patients were due to the intention of themselves or their families, and 2 patients were found to have mild disease severity through angiography and therefore do not require intervention temporarily), 1 required conservative treatment, 4 had surgical contraindications (heart disease, HCY not well controlled, poor general condition and severe depression and mania), and 41 received surgical treatments. The screening process is shown in Figure 1.

Figure 1.

The flowchart of patients’ screening method. The criteria for screening included disease type, stenosis degree, and surgical indications. HCY = homocysteine.

For all SSS patients, data consisted of age, gender, SSS conditions (side and degree), smoking status, and comorbidities (hypertension, hyperlipidemia, hyperhomocysteinemia, diabetes mellitus, CVA/TIA, CAD, pulmonary disease, chronic kidney disease and other arterial disease). For finally screened patients, extra data included surgery information, follow-up data, and stenosis degree of SCA, carotid artery, and vertebral artery on both sides. All patients were comprehensively diagnosed by CTA, Doppler ultrasound, clinical signs, and symptoms. The retrograde flow degree was evaluated by Doppler ultrasound (data not shown) and the stenosis degree was measured by CTA. Surgical indications were mentioned therein before, patients who only accorded with surgical indications of one disease would receive surgical or medical treatment of the corresponding disease, and patients who fit both would be included in the study queue for further analysis. Since it was a retrospective study, patients with missing clinical data were not included.

Surgical method, perioperative period, and follow-up

For patients who need surgical treatment, the technical procedure for open surgery and stent types for endovascular surgery were decided by the surgeon. All the operations were selective, and treated within 1 month after clear indications for surgical treatment. Also, all surgeries were performed by senior doctors at our center to reduce the differences in prognoses caused by surgical techniques. Basic selection principles included stenosis degree and severity of symptoms, we gave priority to the lesion with more severe stenosis or the responsible vessel with corresponding symptoms. If there is a certain conflict between these two conditions, priority should be given to the treatment of more urgent diseases. For example, if no intervention were taken, the possibility of cerebral infarction happening in the short term would be high, and at this time, we would give priority to the corresponding responsible vessel. If the lesions on both sides need to be operated on as soon as possible, then whether to operate at the same time depends on the patient's basic condition (tolerable or not). For those with bilateral severe stenosis patients, we preferred to intervene on one side (the more serious side in most cases) first to make it adapt gradually, otherwise, it would be easy to cause unnecessary ischemia reperfusion injury. Additionally, for patients whose both blood vessels require intervention, if the interval between two operations is less than 3 months, and the second operation is planned previously, it would be considered to be performed at the same time.

As for stent implantation, the stents implanted were produced by Abbott, Boston, Cordis, and Medtronic. Besides, a brain protection umbrella device (Abbott, Cordis) was commonly used in CAS. In CEA surgery, we establish a bypass system from the common carotid artery to the internal carotid artery and suture the carotid incision with a patch after endarterectomy. In CST and axillo-axillary bypass surgery, we achieve the bypass through artificial blood vessels (GORE). The anesthesia methods included general anesthesia for open surgery and local anesthesia for endovascular surgery.

The perioperative period was defined as 30 days after operation, and follow-up was completed through outpatient service, telephone, or online at 1 and 6 months after surgery and annually. For patients followed up via telephone or online, if there appeared abnormalities, they provided relevant examination reports or came to us for follow-up visits. The primary end points of this study were the mortality in these patients, and the secondary end points were vessel re-stenosis or other complications.

Statistical analysis

Statistical analysis was performed by IBM SPSS statistics, version 26.0. Continuous variables were described as means and standard deviations (mean ± SD) and the differences between groups were compared using the student T test or the Mann–Whitney U test according to the normality of data (Kolmogorov–Smirnov test and Shapiro–Wilk test). Categorial data were expressed with counts and percentage (%) and were analyzed using Fisher's exact test. Kaplan–Meier survival curve was used to analyze the prognosis data and binary logistic regression analysis was used to analyze the risk factors of SSS combined with carotid stenosis.

Results

Demographic data and risk factors

Overall, 169 patients have been diagnosed with SSS from January 2015 to October 2022. Among them, 51 patients combined with carotid artery stenosis and had surgical indications for both diseases; the differences between these two groups are shown in Table 1. The simple SSS group had a lower age (60.51 ± 9.304 versus 66.69 ± 7.921, P < .001) and male proportion (57.6% versus 86.3%, P < .001), while similar patterns of lesion sides and stenosis degree were observed in two groups. For comorbidities and habits, the simple SSS group had a significantly lower rate of hyperhomocysteinemia (30.5% vs 51.0%, P = .015; OR = 2.369, [95% CI, 1.207–4.650]), diabetes mellitus (21.2% vs 37.3%, P = .036; OR = 2.209, [95% CI, 1.076–4.534]), CVA (cerebrovascular accident) or TIA (transient ischemic attack) (21.2% vs 37.3%, P = .036; OR = 2.209, [95% CI, 1.076–4.534]), other peripheral arterial diseases like limb ischemia or intermittent claudication (29.7% vs 47.1%, P = .035; OR = 2.108, [95% CI, 1.071–4.148]), and smoking (49.2% vs 68.6%, P = .014; OR = 2.263, [95% CI, 1.132–4.525]. Through the binary multifactor logistic regression analysis, we discovered that age, gender, hyperhomocysteinemia, and diabetes mellitus could all be considered as risk factors for combing carotid artery stenosis (Figure 2).

Figure 2.

The risk factors of SSS patients combining with carotid stenosis. Binary multifactor logistic regression analysis revealed a significant OR ratio among age, gender, hyperhomocysteinemia, and diabetes mellitus.

Table 1.

The demographical characteristics of SSS groups with and without carotid artery stenosis.

	Simple SSS (N = 118)	SSS with carotid stenosis (N = 51)	P value
Age	60.51 ± 9.304	66.69 ± 7.921	<.001^a
Male sex	68 (57.6)	44 (86.3)	<.001^a
Lesion side
Left	90 (76.3)	37 (72.5)	.126
Right	28 (23.7)	12 (23.5)
Both	0 (0.0)	2 (3.9)
Degree of SCA stenosis
Stenosis	77 (65.3)	35 (68.6)	.725
Occlusion	41 (34.7)	16 (31.4)
Comorbidities
Hypertension	62 (52.5)	28 (54.9)	.867
Hyperlipidemia	38 (32.2)	19 (37.3)	.596
Hyperhomocysteinemia	36 (30.5)	26 (51.0)	.015^a
Diabetes mellitus	25 (21.2)	19 (37.3)	.036^a
CVA or TIA	25 (21.2)	19 (37.3)	.036^a
CAD	28 (23.7)	17 (33.3)	.255
Pulmonary disease	16 (13.6)	4 (7.8)	.319
Chronic kidney disease	12 (10.2)	4 (7.8)	.779
Dialysis treatment	0 (0.0)	0 (0.0)
Other arterial disease	35 (29.7)	24 (47.1)	.035^a
Smoking	58 (49.2)	35 (68.6)	.014^a

Abbreviations: CAD = coronary artery disease.

Significant difference (P < .05) between the two groups.

Stenosis conditions, symptoms, and surgical indications

The stenosis degree statistics of three important blood vessels in the neck (SCA, CCA/ICA, and VA) of all 41 patients who had both operation indications and received surgical treatment are shown in Supplemental Table 1. Severe subclavian artery stenosis or occlusion can be detected in more than 90% of patients. For the contralateral side, half patients had none or only mild stenosis, and only two of them (4.9%) presented bilateral steal phenomenon. In comparison, ipsilateral carotid artery involvement is more common than contralateral. The inclusion criteria and symptom distribution of the operation cohort are shown in Supplemental Tables 2 and 3.

Operation procedures: Among the surgical cohort, 24 patients (58.54%) received interventions for SCA (23 for stents and 1 for axillo-axillary bypass), 12 patients (29.27%) underwent carotid artery surgery (6 for stents and 6 for CEA), and 5 patients (12.19%) intervened both SCA and CA contemporaneously (1 for CEA + CST, 3 for CEA + stents, and 1 for stents + stents) (Figure 3). Although in principle, intervention is required for both blood vessels in these patients, we hope to minimize the likelihood of injury and complications. Therefore, if conditions permit (will not affect symptom improvement or leave potential risks behind) or it was expected that the corresponding symptoms can be improved after treatment on only one side, intervention should be minimized and priority would be given to the side with greater impact. All operations were successfully completed and the intraoperative DSA results were satisfactory.

Figure 3.

The perioperative and long-term complications of different operation types (N = 41). Patients who received surgical treatments fall into three main categories and seven subgroups according to surgical methods. Perioperative complications and corresponding operations were displayed in the last row.

Perioperative period

No patient died within 30 days after the operation, and all postoperative events were revealed in Figure 3. Patient 1 had severe stenosis of left SCA and occlusion of ipsilateral ICA before operation. This patient developed stoke 1 day after receiving left SCA balloon dilation and stent implantation and was discharged 1 month after the operation. Patient 2 had severe stenosis of left SCA and right ICA and underwent stent implantation in SCA, who was suddenly deaf in the left ear 1 week after surgery, received hormone and neurotrophic therapy and was discharged 10 days after the operation. Patient 3 had occlusion SCA and ICA ipsilaterally and failed to receive endovascular surgery before in the outer court. The second day after undergoing axillo-axillary bypass surgery, the patient suffered from posterior circulation TIA and was hospitalized for 9 days. Patient 4 had severe stenosis of right ICA and occlusion of contralateral SCA before operation. Incision infection was found several days after the CEA operation. After antibiotic treatment and debridement, the patient was discharged 29 days after surgery.

Long-term follow-up

In a median follow-up of 37.6 months (IQR: Q1, Q3 16, 56 months), three patients lost interview at 12, 12, and 24 months, respectively. None patients died of surgical complications or SSS-related factors, one died of lung cancer 17 months after surgery and one at 61 months after surgery without a clear cause (Figure 4(a)). Figure 4(b)–(e) presented the comparisons between typical preoperative and postoperative images, including the backflow of the vertebral artery and the blood flow reconstruction of the proximal subclavian artery.

Figure 4.

The survival rate and imaging performance during long-term follow-up. (a) The survival rate (N = 41) of a median follow-up of 37.6 months (IQR: Q1, Q3 16, 56 months) was presented by Kaplan–Meier survival plots. Two patients were involved at 17 and 61 months, respectively. The ultrasonic spectrum of vertebral artery: (b) preoperative and (c) postoperative. The CTA sagittal reconstruction (d) before and (e) after operation.

Four events occurred during long-term follow-up. For patients who first implanted SCA stents, one developed renal failure 1 month after the operation and was supposed to be caused by a contrast agent, while the other two found stent restenosis 1 year and more than 2 years after the operation, respectively. Besides, one patient who underwent CEA and SCA stent implantation contemporaneously developed stent restenosis and steal phenomenon again, who underwent balloon dilatation 7 months later.

Comparisons of postoperative complications rate

As Table 2 concluded, for postoperative complications, cerebrovascular complications account for the largest proportion during the perioperative period and stent stenosis was most likely to occur in long-term follow-up. There is no significant difference in postoperative complications between the intervention of SCA and CA (as Table 2 shows). As for simple SSS patients, 90 of them received surgical treatments (stent implantation, n = 88; subclavian–subclavian transposition, n = 1; endovascular repair, n = 1) and no events occurred during the perioperative period, which showed significant differences in surgical complications compared to 41 cases of SSS combined with CAS (Supplemental Table 4, no difference in surgical techniques among two groups). Therefore, SSS combined with carotid artery stenosis might enhance the perioperative complication rate, which is necessary to arouse the attention of surgeons and make full preparations before the operation.

Table 2.

The complications statistics of patients receiving surgery (n = 41).

	SCA intervention (N = 24)	CA intervention (N = 12)	SCA + CA intervention (N = 5)	P value
Death	1 (4.2)	1 (8.3)	0 (0.0)	.744
Operation related	0 (0.0)	0 (0.0)	0 (0.0)	/
Nonoperation related	1 (4.2)	1 (8.3)	0 (0.0)	.744
Perioperative complications	3 (12.5)	1 (8.3)	0 (0.0)	.679
Cerebrovascular	2 (8.3)	0 (0.0)	0 (0.0)	.475
Infection	0 (0.0)	1 (8.3)	0 (0.0)	.290
Others	1 (4.2)	0 (0.0)	0 (0.0)	.696
Long-term complications	3 (12.5)	0 (0.0)	1 (20.0)	.350
Stent restenosis	2 (8.3)	0 (0.0)	1 (20.0)	.338
Contrast medium related	1 (4.2)	0 (0.0)	0 (0.0)	.696
Others	0 (0.0)	0 (0.0)	0 (0.0)	/
Re-intervention	0 (0.0)	0 (0.0)	1 (20.0)	.025^a

Abbreviations: CA = carotid artery; SCA = subclavian artery.

All data were given as counts (percentage).

Significant difference (P < .05) between three groups.

Discussion

Incidence rate

Both SSS and carotid artery stenosis can be attributable to degenerative diseases, due to narrowing or obstruction of the lumen, and thus they may have similarities in pathogenesis. In the cohort of our study, the rate of SSS combined with moderate and severe stenosis of at least one carotid artery is 37.9% (64/169) and 26.7% (45/169). Besides, patients with bilateral SSS occupied 1.2% (2/169) of the entire queue. Bilateral SSS was first reported in the 1960s, relevant literatures were mostly presented in case reports due to its rareness, previous studies showed that only 5% of SSS may involve both sides.^21,22 Because the sample size is small, and the cohort only covers hospitalized patients, it cannot be used as a good incidence rate estimation model of complications’ prevalence.

Risk factors

Besides surgery selection and patients’ outcomes, the risk factors of combining carotid artery stenosis should also be attention. In our study, the risk factors included age, gender, hyperhomocysteinemia, diabetes mellitus, CVA or TIA, and other arterial disease. Since the pathogenesis of both diseases and the risk factors obtained in our article are atherosclerosis related, we assume that there is a certain correlation between these and the severity of atherosclerosis, which needs further studies to verify.

Disease identification

To our knowledge, although these two diseases all had clear surgical indications before, there is no previous study to discuss the diagnosis and treatment mode of patients suffering from both diseases and deciding which one should be more urgent to deal with in patients suffering from both diseases would not be an easy thing since similar symptoms may occur. From the anatomical aspect, SSS is more likely to affect the blood supply of posterior circulation, while the other one has closer correlations with anterior circulation. Because of the existence of the Willis circle, it is feasible to steal blood from bilateral internal carotid arteries as well as contralateral vertebral artery and made the judgment of blood stealing pathway and responsible blood vessels become complicated.

In general, the symptoms of anterior and posterior circulation involvement have a certain degree of overlap like dizziness and nausea. There have been studies to compare and analyze the typical symptoms of stroke in anterior and posterior circulation. Tao et al. studied more than 1000 ACI (anterior circulation infarction) or PCI (posterior circulation infarction) patients and pointed out that Horner's syndrome, crossed sensory deficits, quadrantanopia, oculomotor nerve palsy, and crossed motor deficits are more dominant in PCI (P < .001), but with low sensitivity (1.3–4.0%).²³ Olivato et al. verified e-NIHSS (expanded NIHSS) as a more effective tool to evaluate anterior and posterior circulation strokes.²⁴ As in our cohort, more patients have not suffered from a stroke, so it is unlikely to judge the responsible vessels from symptoms, but it still has certain guiding significance for whether surgical intervention is needed.

Operation selection

For operation selection, we usually considered the following aspects: (1) Stenosis degree, whether the degree of stenosis between CA and SCA differs a lot. SSS did not always represent the existence of a severe stenosis SCA, and the patient's symptoms might result from moderate or severe CA stenosis in this situation. Therefore, when the degree of stenosis varies greatly and there is no potential danger, we choose to give priority to the treatment of more serious lesions, that is, the responsible vessels. (2) High risk of serious events, TIA, and stroke are more likely to occur when the disease is severe, and once happens, the prognosis will be affected. When the patient has experienced such a phenomenon or has a high risk in the short term, we will give priority to the treatment of the corresponding vessels. (3) Postoperative complications, ischemia-reperfusion injury may occur after the opening of blood vessels after long-term stenosis or blockage, and the risk will increase significantly with the number and degree of stenosis. Just like dealing with bilateral CA, sometimes we may intervene on the lighter side first, so that the body can recover part blood supply, providing sufficient time and conditions for staged processing, some patients in this cohort also use the same processing method. (4) General conditions and different surgical methods represent different degrees of risks. In the same way, different basic conditions of patients also determine the level of risk they can bear. Therefore, the balance between these two should also be paid attention to. In comprehensive consideration, the severity and urgency of the affected situation, expected improvement, surgical risk, and postoperative complications are the main concerns.

Postoperative complications

In our cohort, no events happened during the operation and four cases took place within 30 days after the operation. The occurrence of early postoperative complications of patient 1 and patient 3 may be related to poor basic conditions. Patient 1 is complicated with multiple diseases and has suffered from cerebral infarction, and patient 3 failed to open the occluded subclavian artery in the external hospital before. Fortunately, both patients have recovered well and received good feedback in the latest follow-up, for 1 and 8 years, respectively. Patient 2 suffered from nervous deafness 1 week after surgery, which is uncertain whether it is directly related to surgery. This patient's condition was improved later and had a good condition up to the latest follow-up at 4 years. The wound infection of patient 4 may be related to inadequate perioperative incision care or diabetes, and healed after secondary debridement. At the latest 1-year follow-up, there were no abnormalities.

As for the long-term recovery after an operation, two patients (8.7%) inspected in-stent restenosis (ISR) after SCA stent implantation, while the complication rates reported in the literature were 18.7% and 17.4%, which is largely due to deviations in sample size and patient baseline status.^25,26 For atherosclerotic subclavian artery stenosis patients with or without cranio-cervical artery stenosis, the patency rate was 82.4% and 89.7%, respectively, during 27 ± 20 months of follow-up.²⁷ The incidence rate of contrast-induced nephropathy had a wide range of variations according to previews literatures.²⁸ There were no long-term events that happened among patients who have received axillo-axillary bypass, CAS or CEA in our cohort. In other studies, patients implanted with axillo-axillary grafts had a 10-year patency rate of 89% and a 1-year patency rate ranging from 93% to 100%.^29,30 A meta-analysis showed the benefits and risks of CAS and CEA in long-term prognosis from different aspects, both have good curative effects in the treatment of single stenosis.³¹

For patients who have been intervened in both vessels at the same time, the research on long-term prognosis is not perfect. An article proposed that performing CST and ipsilateral CEA at the same time will increase the risk of perioperative stroke, with an incidence of 0.32% and 4.73%, respectively.³² Two cases of SSS with bilateral carotid artery stenosis have been reported before, one intervened in the innominate artery and right ICA and the other one received left CEA and subclavian angioplasty.^6,19 In both cases, the risk of neuro-related events was emphasized. Therefore, we also need to be more alert to the occurrence of neuro-complications in the case of multivessel involvement.

Advantages, limitations, and prospects

Our study is the first to combine the tandem lesions of two important blood vessels in the head and neck for analysis and discussion. Previously, more articles started on the carotid artery to study the impact and treatment of tandem lesions like intracranial segment pathological changes or to discuss the impact of subclavian artery and vertebral artery stenosis during carotid artery surgery.^33–35 Furthermore, the current SSS grading method mainly depends on the degree of stenosis in SCA (more detailed ultrasonic data for SCA stenosis degree evaluation has been proposed³⁶) and the blood flow spectrum in VA, which could not well correspond to the symptoms and disease severity. Our research can provide a new thought for improving the grading system, that is, bringing into the status of both CA and VA.

The limitations of this study mainly lie in its retrospective design and the insufficient patients’ quantity. From the results of power analysis and sample size estimation, our observation results are acceptable on continuous variables but have limited efficacy values on bivariate variables. Besides, since the exact operation mode is decided by the surgeon, and different surgeons may have some differences in the way of judgment and selection of operation, there will be some inaccuracies. If we can design a prospective study and develop a more complete guide for the selection of surgical methods, this error will be eliminated. With people's increasing emphasis on health, their lifestyle is also improving, more vascular degenerative diseases are found and intervened at an early stage, also the development of drugs makes more diseases not only rely on surgical treatment. Therefore, the analysis of inpatient data may lead to some deviation in the prevalence of SSS patients.

Conclusion

The situation would be more complicated when SSS patients are complicated with carotid artery stenosis compared to simple SSS. Patients who are male sex or combined with hyperhomocysteinemia or diabetes mellitus are more likely to suffer from it. In this study, we tried to observe and analyze different surgical procedures and their prognosis, hoping to provide data support for constructing a more accurate disease diagnosis and treatment system. However, due to the limited cohort size and retrospective study design, further study would be necessary in the future.

Supplemental Material

sj-docx-2-sci-10.1177_00368504241307470 - Supplemental material for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study

Supplemental material, sj-docx-2-sci-10.1177_00368504241307470 for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study by Haotian Huanggu, Guangchao Gu, Fangda Li, Rong Zeng, Jiang Shao, Xiaojun Song, Zhili Liu and Yuehong Zheng in Science Progress

Supplemental Material

sj-docx-3-sci-10.1177_00368504241307470 - Supplemental material for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study

Supplemental material, sj-docx-3-sci-10.1177_00368504241307470 for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study by Haotian Huanggu, Guangchao Gu, Fangda Li, Rong Zeng, Jiang Shao, Xiaojun Song, Zhili Liu and Yuehong Zheng in Science Progress

Supplemental Material

sj-docx-4-sci-10.1177_00368504241307470 - Supplemental material for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study

Supplemental material, sj-docx-4-sci-10.1177_00368504241307470 for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study by Haotian Huanggu, Guangchao Gu, Fangda Li, Rong Zeng, Jiang Shao, Xiaojun Song, Zhili Liu and Yuehong Zheng in Science Progress

Supplemental Material

sj-docx-5-sci-10.1177_00368504241307470 - Supplemental material for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study

Supplemental material, sj-docx-5-sci-10.1177_00368504241307470 for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study by Haotian Huanggu, Guangchao Gu, Fangda Li, Rong Zeng, Jiang Shao, Xiaojun Song, Zhili Liu and Yuehong Zheng in Science Progress

Supplemental Material

sj-pdf-6-sci-10.1177_00368504241307470 - Supplemental material for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study

Supplemental material, sj-pdf-6-sci-10.1177_00368504241307470 for Surgical outcomes of subclavian steal syndrome combined with carotid artery stenosis: A single-center retrospective observational study by Haotian Huanggu, Guangchao Gu, Fangda Li, Rong Zeng, Jiang Shao, Xiaojun Song, Zhili Liu and Yuehong Zheng in Science Progress

Footnotes

Author contribution

Study design: YZ, HH. Data collection: HH, GG, FL, RZ, JS, XS, ZL, YZ. Writing: HH, GG.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The data that support the findings of this study are available in the additional files of this article.

Ethical approval

All data were collected in the vascular surgery department of Peking Union Medical College Hospital and have been approved by the Ethics Committee of Beijing Union Medical College Hospital, Chinese Academy of Medical Sciences (reference number I-22PJ721).

Funding

This work was funded by the Natural Science Foundation of China [grant numbers 82070492, 82100519]; the National High Level Hospital Clinical Research Funding [grant numbers 2022-PUMCH-A-077, 2022- PUMCH-B-100, 2022-PUMCH-C-062]; the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences [grant number CIFMS 2021-I2M-1-016]; and the Department of Vascular Surgery, State Key Laboratory of Complex Severe and Rare Diseases of Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College.

ORCID iD

Yuehong Zheng

Supplemental material

Supplemental material for this article is available online.

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