title: Iatrogenic vertebrobasilar insufficiency after surgery of the subclavian or brachial artery: review of three cases.
abstract: OBJECTIVE
  Vertebrobasilar insufficiency resulting from disease of the subclavian artery is well recognized. Usually, this occurs as the "subclavian steal" syndrome in the context of chronic subclavian stenosis and is consequently well tolerated because of collateralization. Acute disruption of the hemodynamics of the aortic arch vessels, however, can produce disastrous sequelae.
  
  
  METHODS
  We present three cases of iatrogenic vertebrobasilar insufficiency sustained as complications of surgery of the left subclavian artery or its distal continuation. The cases were chosen from a review of approximately 400 emergency neurosurgery consultations requested at the Los Angeles County Hospital between November 1995 and February 1996.
  
  
  METHODS
  The first patient underwent repair of a traumatic brachial artery occlusion and awoke postoperatively with bilateral cortical blindness, right hemiparesis, and multiple cranial nerve deficits that were most likely caused by acute subclavian steal. The second underwent removal of a subclavian embolus and developed bilateral cerebellar infarction leading to persistent coma, possibly from inadvertent embolization of the vertebral artery during surgery. The third underwent resection and bypass grafting of a subclavian aneurysm. Good backflow was reported when the vertebral artery was disarticulated from the subclavian artery, and this vessel was not reimplanted into the graft. The patient suffered massive cerebellar infarction leading rapidly to brain death.
  
  
  CONCLUSIONS
  There are myriad ways in which the inherent redundancy of the vertebrobasilar system may be jeopardized, and when this protective mechanism fails, the results can be disastrous. Flow through the vertebral arteries may be compromised by thrombosis, embolization, dissection, inappropriate ligation, excessive head rotation, hypotension, vasospasm, or acute subclavian steal. These examples illustrate the importance of understanding the complex physiology of posterior fossa circulation as the basis of pre-, intra-, and postoperative management of patients undergoing surgery of the subclavian artery.
authors.affiliation: Department of Neurological Surgery, University of Southern California, Los Angeles 90033, USA.
authors.forename: A P
authors.initials: AP
authors.lastname: Amar
authors.forename: M L
authors.initials: ML
authors.lastname: Levy
authors.forename: S L
authors.initials: SL
authors.lastname: Giannotta
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000783:Aneurysm / Q000601:surgery*; D001366:Axillary Artery / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation; D001916:Brachial Artery / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*; D001925:Brain Damage, Chronic / Q000209:etiology* / Q000503:physiopathology; D002545:Brain Ischemia / Q000209:etiology / Q000503:physiopathology; D002318:Cardiovascular Diseases / Q000150:complications; D002404:Catheterization / Q000009:adverse effects; D002408:Catheters, Indwelling / Q000009:adverse effects; D002544:Cerebral Infarction / Q000209:etiology* / Q000503:physiopathology; D002560:Cerebrovascular Circulation; D017128:Embolectomy / Q000009:adverse effects*; D004617:Embolism / Q000601:surgery*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D007431:Intraoperative Complications / Q000209:etiology* / Q000503:physiopathology; D008026:Ligation / Q000009:adverse effects; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D018458:Persistent Vegetative State / Q000209:etiology* / Q000503:physiopathology; D011183:Postoperative Complications / Q000209:etiology* / Q000503:physiopathology; D011187:Posture; D012189:Retrospective Studies; D013348:Subclavian Artery / Q000601:surgery*; D013349:Subclavian Steal Syndrome / Q000209:etiology* / Q000503:physiopathology; D014711:Vertebral Artery / Q000293:injuries / Q000601:surgery; D014715:Vertebrobasilar Insufficiency / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control