Anesthetic management of a patient with bilateral subclavian artery stenosis undergoing lower extremity arterial thrombectomy

Anesthetic management of a patient with bilateral subclavian artery stenosis undergoing lower extremity arterial thrombectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Anesthetic management of a patient with bilateral subclavian artery stenosis undergoing lower extremity arterial thrombectomy Hui Yong, Chun-lin WU, Ming-xia He, Wei Ding, Qian Xie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4191168/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Bilateral subclavian artery stenosis is a rare peripheral artery disease. This case study presents a patient who underwent an emergency thrombectomy for this condition. Case presentation The diagnosis of bilateral subclavian artery stenosis was confirmed through perioperative measurement of radial arterial blood pressure in both upper limbs and postoperative examination. Conclusion The study highlights the crucial need for accurately measuring blood pressure in all limbs to prevent perioperative complications resulting from inaccurate readings, delayed interventions, or unnecessary procedures. Bilateral Subclavian Artery Stenosis Emergency Thrombectomy Peripheral Artery Disease Perioperative Complications Figures Figure 1 Figure 2 Figure 3 Background Bilateral subclavian artery stenosis is a rare peripheral artery disease [1, 2] . This case study presents a patient who underwent an emergency thrombectomy for this condition. The diagnosis of bilateral subclavian artery stenosis was confirmed through perioperative measurement of radial arterial blood pressure in both upper limbs and postoperative examination. The study highlights the crucial need for accurately measuring blood pressure in all limbs to prevent perioperative complications resulting from inaccurate readings, delayed interventions, or unnecessary procedures. Case presentation A 68-year-old female presented with a history of persistent left lower limb pain for over 3 years, underwent balloon dilatation of the left lower limb superficial artery, popliteal artery, and anterior tibial artery 8 days prior, with symptoms worsening over the past day. She was admitted to the emergency department with “lower limb arterial thrombosis and arteriosclerosis obliterans”. Her medical history includes hypertension for more than 10 years, with the highest blood pressure readings exceeding 200 mmHg, irregular medication adherence, and inadequate blood pressure management. She has had Type II diabetes for a decade with reasonable blood sugar control. The current medication regimen includes aspirin, rivaroxaban, clopidogrel, and other medications. The patient is alert, reports occasional dizziness, and denies symptoms such as chest tightness, palpitations, and chest pain. Auxiliary examination: the electrocardiogram revealed sinus rhythm with T wave inversions in leads II, III, aVF, and V3-V9; cardiac ultrasound exhibited an enlarged left atrium, thickening of the ventricular septum basal segment, and normal left ventricular systolic function. Furthermore, CT scans of the head, chest, and abdomen demonstrated bilateral basal ganglia lacunar infarctions, white matter demyelination changes, fibrocalcification in both lungs and multi-branch calcification in the coronary arteries. The abdominal CT scan revealed no discernible anomalies. The blood tests indicated mild thrombocytosis, slight elevations in D-dimer and fibrin degradation products (FDP), and a mild prolongation of the prothrombin time. There were no notable abnormalities in liver and kidney function or electrolyte levels. After the patient entered the operating room, -invasive blood pressure readings were 165/74 mmHg on the right side and 225/73 mmHg on the left. Subsequently, a bilateral radial artery puncture was conducted to assess bilaterally arterial blood pressure: the right radial artery pressure was registered at 167/78 mmHg, and the left radial artery pressure was 239/69 mmHg. Venous access was established for rapid fluid replacement. Anesthesia induction: the patient received intravenous administrations of midazolam 2 mg, sufentanil 15 mg, cisatracurium 15 mg, and etomidate 12 mg sequentially. Following this, 2 minutes of assisted ventilation was conducted, followed by tracheal intubation under visual laryngoscopy. The endotracheal tube was size 7.0, inserted to a depth of 22 cm, and bilateral lung breath sounds were symmetrical. Mechanical ventilation was then initiated by connecting the ventilator. The respiratory parameters were adjusted to maintain the end-tidal carbon dioxide between 35-40 cm H 2 O. Cisatracurium was administered at 6 mg/h and remifentanil at 0.1 µg/kg/min intraoperatively, with 1-2% sevoflurane inhalation anesthesia. Following anesthesia induction, the invasive blood pressure measurements for the right and left sides were 115/56 mmHg and 167/50 mmHg, respectively. Upon endotracheal intubation, the invasive blood pressure readings increased to 194/82 mmHg for the right side and 250/70 mmHg for the left side. Subsequently, propofol (50 mg) and sufentanil (5 µg) were administered intravenously. As a result, the invasive blood pressure levels gradually decreased to 140-160/50-70 mmHg for the right side and 180-200/60-70 mmHg for the left side. During the operation, the concentration of sevoflurane and the infusion rate of remifentanil were continuously adjusted to keep the invasive blood pressures within the target ranges: 130-170/50-70 mmHg on the right and 170-210/60-70 mmHg on the left. Following the removal of emboli from the lower limb arteries and vessel unblocking procedures, a gradual decrease in blood pressure was observed on both sides, with readings reaching 80/44 mmHg on the right and 110/47 mmHg on the left. In response, an immediate administration of 2 mg of dopamine was initiated, achieving only a modest increase in blood pressure, leading to intermittent injections of 100 µg of phenylephrine for pressure maintenance. Post-operation, the patient's invasive blood pressures ranged between 140-160/50-70 mmHg on the right and 160-180/60-70 mmHg on the left, after which she was transferred to the ICU. Ambulatory blood pressure measurements at different points of time throughout the procedure are shown in Table 1. The operation lasted 370 minutes, during which the patient received 1500 ml of compound sodium chloride, 1250 ml of polygeline peptide, and 2 units of suspended red blood cells intravenously. The patient experienced an intraoperative blood loss of 800 ml and a urine output of 1800 ml, with two blood gas analyses showing no significant abnormalities. On the day following the surgery, the patient was moved from the ICU to a general ward. Subsequent reevaluations revealed no abnormalities, and she was discharged one-week post-operation. Table 1. Blood Pressure at Different Points during the Perioperative Period Points of time IBP（L） （ mmHg ） IBP（R） （ mmHg ） SBP Difference （mmHg） SBP DBP SBP DBP 1.Entered the operating room 167 69 239 78 72 2.After induction 115 50 167 56 52 3.Tracheal intubation 194 82 250 70 56 4.Surgery begin 142 69 190 73 48 5.Surgery for 30 minutes 136 65 185 69 49 6.Surgery for 1 h 148 72 189 75 41 7.Surgery for 2 h 140 68 180 71 40 8.Surgery for 3 h 136 65 178 68 42 9.Surgery for 4 h 132 62 184 73 52 10.Surgery for 5 h 128 58 175 68 47 11.Remove thrombus 80 44 110 47 30 12.Send to ICU 145 72 178 75 27 Average value 149±37 65±10 175±34 69±8 46±11 Discussion Subclavian artery stenosis, a relatively uncommon manifestation of peripheral artery disease (PAD) [3] , presents a spectrum of symptoms from upper limb ischemia to cerebral hypoperfusion and coronary steal syndrome (SSS) [4, 5] . Subclavian artery stenosis can be identified by measuring asymmetric blood pressure in the upper limbs or detecting a difference in systolic blood pressure greater than 15 mmHg between the two arms [6] . Common risk factors for PAD typically include smoking, hypertension, diabetes, and hyperlipidemia [7] . However, the clinical presentation can vary based on anatomical factors, including the severity and origin of stenosis and the presence of arterial disease in other regions. These manifestations encompass asymmetry in blood pressure within the upper extremities, the absence or weakening of pulses in the axillary, brachial, radial, or ulnar arteries, and the presence of finger ulcers or gangrene [8] . In this case, the patient presented with a minimum of two risk factors, notably hypertension and diabetes mellitus. Additionally, an asymmetry was observed in bilateral arterial pulsations during the radial artery puncture, although no ulcers or gangrene were evident in the fingers. Subclavian artery stenosis typically presents asymptomatically in the majority of patients as the disease advances gradually, with symptoms emerging only when the lumen diameter narrows to less than 50% [9] . Consequently, a heightened suspicion of subclavian artery stenosis is essential when encountering bilateral blood pressure asymmetry in a patient. The patient's head CT showed lacunar cerebral infarction in the bilateral basal ganglia and demyelination changes in the white matter. Additionally, the patient expressed discomfort during activities, notably dizziness, which could be attributed to inadequate blood supply in the brain artery (vertebrobasilar artery) or compromised blood flow in the upper limb artery due to the subclavian steal phenomenon [10] . The pathophysiology involves the redirection of blood flow from the brain to the arm, resulting in symptoms of vertebrobasilar insufficiency, particularly exacerbated by vigorous arm movements or sudden sharp head rotations towards the affected side. These symptoms result from two mechanisms: 1) Blood flow diversion by the arm from the vertebrobasilar region and 2) Inadequate blood supply due to subclavian artery stenosis [11] . The main symptoms include dizziness, vertigo, syncope, ataxia, imbalance, falls, diplopia, nystagmus, hemianopsia, blurred vision, tinnitus, hearing loss, bilateral arm muscle weakness, and others [12] . The patient's electrocardiogram displayed low and inverted T waves in leads II, III, avF, and V3-V9, while the echocardiogram revealed left atrial enlargement and thickening of the basal ventricular septum. These findings indicate the presence of myocardial ischemia and associated structural changes, potentially linked to subclavian artery stenosis. Typically, the proximal end of the left internal mammary artery (LIMA) connects to the left subclavian artery [13] . After resection, its distal end is anastomosed to the compromised epicardial coronary artery. Proximal stenosis of the left subclavian artery leads to a reversal of blood flow from the heart towards the left internal mammary artery to maintain adequate blood perfusion in the left upper extremity. This phenomenon is recognized as coronary-subclavian steal syndrome (CSSS) [14] . CSSS can result in myocardial ischemia, angina pectoris, acute coronary syndrome, heart failure, and severe ventricular arrhythmias [15, 16] . Perioperative blood pressure management is pivotal in patient care, ensuring optimal perfusion of vital organs by maintaining an ideal blood pressure level. Adequate blood pressure management in patients with subclavian artery pathology is critical, as inaccurate blood pressure readings can mislead anesthesiologists and result in delayed interventions. This situation can lead to prolonged periods of hypotension and hypoperfusion during the perioperative phase, increasing the risk of stroke and multiple organ failure for the patients. Moreover, inappropriate interventions, including the excessive use of vasoactive medications, can further strain the cardiovascular and neurological systems, ultimately contributing to a poorer prognosis. Given the variability in bilateral upper limb SBP differences among patients with subclavian artery stenosis, it is essential to establish personalized blood pressure management targets. Typically, in patients with subclavian artery stenosis, bilateral brachial artery blood pressure is assessed using a cuff, and invasive radial artery blood pressure is monitored on one side while cuff blood pressure is taken on the other [6] . Blood pressure measurements may be inaccurate due to the use of cuffs that are either too loose, too wide, or of inappropriate size. In this case, direct intravascular pressure measurement through bilaterally assessing the radial artery enables continuous, reliable, and accurate blood pressure values, serving as the gold standard for blood pressure monitoring.In addition, we found that despite the large differences between the two sides, the changes in invasive blood pressure on the left and right sides were relatively consistent (as shown in Figure 1), which indicates that dynamic measurement of bilateral invasive blood pressure is necessary. During perioperative anesthesia management, it is crucial to regulate both decreases and elevations in blood pressure, minimize sudden and extreme blood pressure fluctuations, and aim to keep blood pressure fluctuations within ±20% to prevent the onset of coronary steal syndrome and stroke. The inter-arm blood pressure difference (IABDP) > 10 mm Hg suggests asymmetric stenosis in the upper arm artery, with reduced blood pressure on the stenotic side [17] ; IASBPD≥15mm Hg has high specificity and moderate sensitivity for the diagnosis of subclavian stenosis [18] . Patients with IABDP greater than 10 mmHg are more likely to develop coronary artery disease, peripheral artery stenosis, and other cardiovascular events. In addition, they have higher morbidity and mortality. For every 1 mmHg increase in IABDP, the risk of 10-year cardiovascular mortality increased by 1% to 2% [19] . Min Li et al. showed that the risk of cardiovascular death was increased by 88% in patients with IABDP≥10mm Hg and by 93% in patients with IASBPD≥15mm Hg [20] . The pathological foundation of IABDP lies in the asymmetrical stenosis of the bilateral subclavian artery, axillary artery, and brachial artery, which can manifest unilaterally or bilaterally. Involvement of the left subclavian artery is more common than the proper or innominate artery, with the incidence of left subclavian artery stenosis being four times that of the right subclavian artery [2] . Lower blood pressure occurs on the side of the artery with stenosis or more severe stenosis, resulting in developing IABDP. In this case, the patient presented an uncommon occurrence of bilateral subclavian artery stenosis, as depicted in Figure 3 (moderate to severe stenosis on the left side and mild to moderate on the right side). Previous studies have indicated lower blood pressure on the side with stenosis. Notably, in this case, the systolic blood pressure in the right radial artery was significantly higher than that in the left, with a substantial difference of 46±11 mmHg between the two. The siphon effect causes blood to flow from the ipsilateral vertebral artery backward into the subclavian artery, while blood from the corresponding contralateral artery flows into the distal end of the occluded artery through the communicating artery to compensate, this mechanism increases systolic blood pressure on the side with more severe stenosis. It is also worth noting that with the removal of the lower limb thrombus, the SBP Difference between the two sides decreased significantly (as shown in Figure 2). Whether the IABDP is related to the lower limb thrombosis, and whether the formation of lower limb thrombosis is related to the stenosis of the subclavian artery, is a question worthy of further investigation. In cases of subclavian artery stenosis, it is imperative to promptly measure the blood pressure in the extremities. In this instance, we only measured the radial artery blood pressure of both upper limbs, the main reason was that we did not know whether the patient had subclavian artery stenosis or rare bilateral subclavian artery stenosis before surgery, and the patient underwent emergency left lower limb artery incision thrombectomy, we did not have sufficient time for further diagnosis. To enhance accuracy and ensure stable blood pressure maintenance during the operation while minimizing postoperative complications, it may be helpful to us to compare the non-invasive blood pressure in the right lower limb. Summary Special attention should be given to synchronously measuring blood pressure in both upper limbs or all four limbs of patients with subclavian artery stenosis. As blood pressure is subject to dynamic changes and can vary when measured by the same individual at different times, synchronous measurements help mitigate these fluctuations, yielding more precise results. Before operation, we should actively control the patient's blood pressure to normal level, avoid hemodynamic fluctuations, and reduce the occurrence of cerebrovascular accident. Limb blood pressure measurement has gained recognition for its efficacy in screening and diagnosing peripheral arterial disease. Moreover, it is increasingly significant in evaluating cardiovascular disease risk, screening subclinical atherosclerotic disease, and predicting cardiovascular events. As interest in limb blood pressure measurement grows, this straightforward and cost-effective method is expected to have a more pronounced impact on clinical practice in screening and diagnosing peripheral vascular disease and high-risk cardiovascular conditions. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests The authors declare no competing interests. Funding Not applicable. Authors’ contributions XQ wrote the paper; WCL followed-up the patient and participated in the treatment and management of patient; HMX and DW helped to correct the article; YH conceptualized the idea and finalized the manuscript; All authors have read and approve the final manuscript. Acknowledgements Not applicable. References Caesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). Ahmed MA, Parwani D, Mahawar A, Gorantla VR. Subclavian Artery Calcification: A Narrative Review. Cureus. 2022. 14(3): e23312. Patel R, White CJ. Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists. Prog Cardiovasc Dis. 2021. 65: 44-48. An X, Dong H, Deng Y, et al. Evaluation of the role of combining inter-arm systolic pressure difference and derivatives of pulse volume recording in detecting subclavian artery stenosis. Front Cardiovasc Med. 2022. 9: 962610. Caesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). Adams M, Sousa CP, Duarte S, Machado H. When the Conception of Symmetry Deceives Us: A Case Report on the Perioperative Diagnosis of Subclavian Artery Stenosis. Cureus. 2023. 15(11): e48699. Prasad A, Wassel CL, Jensky NE, Allison MA. The epidemiology of subclavian artery calcification. J Vasc Surg. 2011. 54(5): 1408-13. Patil C, Kotamraju S, Kumar P, Kollu R, Reddy M. Right Vertebral Artery Arising From Ipsilateral Common Carotid Artery With Severe Stenosis of Ostio-proximal Segment of Aberrant Right Subclavian Artery: A Rare Life-Saving Variant. Cureus. 2022. 14(6): e25566. Caesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). Shankar Kikkeri N, Nagalli S. StatPearls. 2024. Treasure Island (FL). Zavaruev AV. [Subclavian steal syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova. 2017. 117(1): 72-77. Song D, Ireifej B, Seen T, Almas T, Sattar Y, Chadi Alraies M. Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis. Ann Med Surg (Lond). 2021. 68: 102597. Steinberger J, Georgie F, Zughaib M. Coronary Subclavian Steal Syndrome in a 73-Year-Old Woman Presenting with Angiographically Confirmed Subclavian Artery Stenosis Proximal to the Left Internal Mammary. Am J Case Rep. 2022. 23: e937015. Lak HM, Shah R, Verma BR, Roselli E, Caputo F, Xu B. Coronary Subclavian Steal Syndrome: A Contemporary Review. Cardiology. 2020. 145(9): 601-607. Mandak J, Lojik M, Tuna M, Chek JL. Coronary subclavian steal syndrome causing acute myocardial infarction in a patient undergoing coronary-artery bypass grafting. Case Rep Med. 2012. 2012: 798356. Wu CH, Sung SH, Chang JC, Huang CH, Lu TM. Subclavian artery thrombosis associated with acute ST-segment elevation myocardial infarction. Ann Thorac Surg. 2009. 88(6): 2036-8. English JA, Carell ES, Guidera SA, Tripp HF. Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv. 2001. 54(1): 8-11. Aboyans V, Kamineni A, Allison MA, et al. The epidemiology of subclavian stenosis and its association with markers of subclinical atherosclerosis: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2010. 211(1): 266-70. Heshmat-Ghahdarijani K, Ghasempour Dabaghi G, Rabiee Rad M, Bahri Najafi M. The Relation Between Inter Arm Blood Pressure Difference and Presence of Cardiovascular Disease: A Review of Current Findings. Curr Probl Cardiol. 2022. 47(11): 101087. Li M, Fan F, Qiu L, Ma W, Zhang Y. Association of an inter-arm systolic blood pressure difference with all-cause and cardiovascular mortality: A meta-analysis of cohort studies. J Clin Hypertens (Greenwich). 2023. 25(12): 1069-1078. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.zip Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4191168","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":288955296,"identity":"c8e659bc-d3d7-4ecb-9e11-0cc0a5249c3d","order_by":0,"name":"Hui Yong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACNmb+jw8SKiR47JuZDxCnhY+9wdjgwxkLOQP2tgTitMjxHDATnNlWYWzAc8aASIdJJKQx87BJJG6XyPl44w2DnZxuA2Etxx7z8Egk7pyRu9lyDkOysdkBgloS2415JCQSG27kbpPmYTiQuI2wlmQ2aR4DkJacZ0Rq4TnGJjkjQcLY4MwZNiK1sPcwG3w4ICEn2d5mbDnHgAi/yDfzMD5I/FfHw8/M/PDGmwo7OYJaUIAED5FRg6yFVB2jYBSMglEwIgAAL+g+XpKYf9kAAAAASUVORK5CYII=","orcid":"","institution":"Department of Anesthesia, Hospital of Chengdu University of Traditional Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Hui","middleName":"","lastName":"Yong","suffix":""},{"id":288955298,"identity":"a2fb77fc-c663-4c68-9492-843b178e8063","order_by":1,"name":"Chun-lin WU","email":"","orcid":"","institution":"Department of Anesthesia, Hospital of Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chun-lin","middleName":"","lastName":"WU","suffix":""},{"id":288955301,"identity":"e9c76475-a6d8-4ed7-ac51-3bf4227e6dd6","order_by":2,"name":"Ming-xia He","email":"","orcid":"","institution":"Department of Anesthesia, Hospital of Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ming-xia","middleName":"","lastName":"He","suffix":""},{"id":288955304,"identity":"a027f67a-4ece-468f-9ec5-11bceca7c0da","order_by":3,"name":"Wei Ding","email":"","orcid":"","institution":"Department of Anesthesia, Hospital of Chengdu University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Ding","suffix":""},{"id":288955306,"identity":"64619b44-d1b2-429e-81c7-43a4d5bbf233","order_by":4,"name":"Qian Xie","email":"","orcid":"","institution":"Department of Anesthesiology, the First Affiliated Hospital, Jinan University","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Xie","suffix":""}],"badges":[],"createdAt":"2024-03-30 07:51:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4191168/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4191168/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54445002,"identity":"724a0867-2716-4649-a313-f6ad63c8e054","added_by":"auto","created_at":"2024-04-10 16:14:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":190545,"visible":true,"origin":"","legend":"\u003cp\u003eTrend plot of Left and Right Systolic Blood Pressure\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4191168/v1/8e66cb0be00fe8f29416bc7e.png"},{"id":54445003,"identity":"c57b00c4-3f19-43aa-b24e-4ce0949e5ae4","added_by":"auto","created_at":"2024-04-10 16:14:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63030,"visible":true,"origin":"","legend":"\u003cp\u003eTrend plot of SBP Difference between\u003c/p\u003e\n\u003cp\u003ethe left and right sides\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4191168/v1/2cbd47d4a134ae39f75e2cdd.png"},{"id":54445004,"identity":"74d4fd52-6d7f-485a-aff4-13ffa2ea421c","added_by":"auto","created_at":"2024-04-10 16:14:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":680058,"visible":true,"origin":"","legend":"\u003cp\u003eCT of the Chest\u003c/p\u003e\n\u003cp\u003eLeft subclavian artery（LSCA）; Right Subclavian Artery （RSA）\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4191168/v1/1b1ee6ebad35838e5d21b263.png"},{"id":58204132,"identity":"d0be150f-6b23-43f0-b0af-e8679da21e14","added_by":"auto","created_at":"2024-06-12 11:36:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1144045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4191168/v1/2613a455-e0b6-4fc3-948e-d4b047f90a4d.pdf"},{"id":54445006,"identity":"8be28b67-af03-4ac6-9b6c-4b3c175c6573","added_by":"auto","created_at":"2024-04-10 16:14:33","extension":"zip","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2222935,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.zip","url":"https://assets-eu.researchsquare.com/files/rs-4191168/v1/b1bb971479c13a4a5c3e0d15.zip"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anesthetic management of a patient with bilateral subclavian artery stenosis undergoing lower extremity arterial thrombectomy","fulltext":[{"header":"Background","content":"\u003cp\u003eBilateral subclavian artery stenosis is a rare peripheral artery disease\u003csup\u003e[1, 2]\u003c/sup\u003e. This case study presents a patient who underwent an emergency thrombectomy for this condition. The diagnosis of bilateral subclavian artery stenosis was confirmed through perioperative measurement of radial arterial blood pressure in both upper limbs and postoperative examination. The study highlights the crucial need for accurately measuring blood pressure in all limbs to prevent perioperative complications resulting from inaccurate readings, delayed interventions, or unnecessary procedures.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 68-year-old female presented with a history of persistent left lower limb pain for over 3 years, underwent balloon dilatation of the left lower limb superficial artery, popliteal artery, and anterior tibial artery 8 days prior, with symptoms worsening over the past day. She was admitted to the emergency department with \u0026ldquo;lower limb arterial thrombosis and arteriosclerosis obliterans\u0026rdquo;. Her medical history includes hypertension for more than 10 years, with the highest blood pressure readings exceeding 200 mmHg, irregular medication adherence, and inadequate blood pressure management. She has had Type II diabetes for a decade with reasonable blood sugar control. The current medication regimen includes aspirin, rivaroxaban, clopidogrel, and other medications. The patient is alert, reports occasional dizziness, and denies symptoms such as chest tightness, palpitations, and chest pain. Auxiliary examination: the electrocardiogram revealed sinus rhythm with T wave inversions in leads II, III, aVF, and V3-V9; cardiac ultrasound exhibited an enlarged left atrium, thickening of the ventricular septum basal segment, and normal left ventricular systolic function. Furthermore, CT scans of the head, chest, and abdomen demonstrated bilateral basal ganglia lacunar infarctions, white matter demyelination changes, fibrocalcification in both lungs and multi-branch calcification in the coronary arteries. The abdominal CT scan revealed no discernible anomalies. The blood tests indicated mild thrombocytosis, slight elevations in D-dimer and fibrin degradation products (FDP), and a mild prolongation of the prothrombin time. There were no notable abnormalities in liver and kidney function or electrolyte levels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the patient entered the\u0026nbsp;operating\u0026nbsp;room, -invasive blood pressure readings were 165/74 mmHg on the right side and 225/73 mmHg on the left.\u0026nbsp;Subsequently, a bilateral radial artery puncture was conducted to assess bilaterally arterial blood pressure: the right radial artery pressure was registered at 167/78 mmHg, and the left radial artery pressure was 239/69 mmHg. Venous access was established for rapid fluid replacement. Anesthesia induction: the patient received intravenous administrations of midazolam 2 mg, sufentanil 15 mg, cisatracurium 15 mg, and etomidate 12 mg sequentially. Following this, 2 minutes of assisted ventilation was conducted, followed by tracheal intubation under visual laryngoscopy. The endotracheal tube was size 7.0, inserted to a depth of 22 cm, and bilateral lung breath sounds were symmetrical. Mechanical ventilation was then initiated by connecting the ventilator. The respiratory parameters were adjusted to maintain the end-tidal carbon dioxide between 35-40 cm H\u003csub\u003e2\u003c/sub\u003eO. Cisatracurium was administered at 6 mg/h and remifentanil at 0.1 \u0026micro;g/kg/min intraoperatively, with 1-2% sevoflurane inhalation anesthesia. Following anesthesia induction, the invasive blood pressure measurements for the right and left sides were 115/56 mmHg and 167/50 mmHg, respectively. Upon endotracheal intubation, the invasive blood pressure readings increased to 194/82 mmHg for the right side and 250/70 mmHg for the left side. Subsequently, propofol (50 mg) and sufentanil (5 \u0026micro;g) were administered intravenously. As a result, the invasive blood pressure levels gradually decreased to 140-160/50-70 mmHg for the right side and 180-200/60-70 mmHg for the left side. During the operation, the concentration of sevoflurane and the infusion rate of remifentanil were continuously adjusted to keep the invasive blood pressures within the target ranges: 130-170/50-70 mmHg on the right and 170-210/60-70 mmHg on the left. Following the removal of emboli from the lower limb arteries and vessel unblocking procedures, a gradual decrease in blood pressure was observed on both sides, with readings reaching 80/44 mmHg on the right and 110/47 mmHg on the left. In response, an immediate administration of 2 mg of dopamine was initiated, achieving only a modest increase in blood pressure, leading to intermittent injections of 100 \u0026micro;g of phenylephrine for pressure maintenance. Post-operation, the patient\u0026apos;s invasive blood pressures ranged between 140-160/50-70 mmHg on the right and 160-180/60-70 mmHg on the left, after which she was transferred to the ICU. Ambulatory blood pressure measurements at different points of time throughout the procedure are shown in Table 1. The operation lasted 370 minutes, during which the patient received 1500 ml of compound sodium chloride, 1250 ml of polygeline peptide, and 2 units of suspended red blood cells intravenously. The patient experienced an intraoperative blood loss of 800 ml and a urine output of 1800 ml, with two blood gas analyses showing no significant abnormalities. On the day following the surgery, the patient was moved from the ICU to a general ward. Subsequent reevaluations revealed no abnormalities, and she was discharged one-week post-operation.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Blood Pressure at Different Points during the Perioperative Period\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"114%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.673469387755105%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePoints\u0026nbsp;of time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.551020408163264%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIBP（L）\u003c/p\u003e\n \u003cp\u003e\u003cu\u003e（\u003c/u\u003e\u003cu\u003emmHg\u003c/u\u003e\u003cu\u003e）\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.510204081632654%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eIBP（R）\u003c/p\u003e\n \u003cp\u003e\u003cu\u003e（\u003c/u\u003e\u003cu\u003emmHg\u003c/u\u003e\u003cu\u003e）\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.26530612244898%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSBP\u003c/p\u003e\n \u003cp\u003eDifference\u003c/p\u003e\n \u003cp\u003e（mmHg）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.45098039215686%\" valign=\"top\"\u003e\n \u003cp\u003eSBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.529411764705884%\" valign=\"top\"\u003e\n \u003cp\u003eDBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.45098039215686%\" valign=\"top\"\u003e\n \u003cp\u003eSBP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.568627450980394%\" valign=\"top\"\u003e\n \u003cp\u003eDBP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e1.Entered the operating room\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e2.After induction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e3.Tracheal intubation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e4.Surgery begin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e5.Surgery for 30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e6.Surgery for 1 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e7.Surgery for 2 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e8.Surgery for 3 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e136\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e9.Surgery for 4 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e10.Surgery for 5 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e11.Remove thrombus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e12.Send to ICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e145\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.02061855670103%\" valign=\"top\"\u003e\n \u003cp\u003eAverage value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e149\u0026plusmn;37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\" valign=\"top\"\u003e\n \u003cp\u003e65\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\" valign=\"top\"\u003e\n \u003cp\u003e175\u0026plusmn;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\" valign=\"top\"\u003e\n \u003cp\u003e69\u0026plusmn;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e46\u0026plusmn;11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eSubclavian artery stenosis, a relatively uncommon manifestation of peripheral artery disease (PAD)\u003csup\u003e[3]\u003c/sup\u003e, presents a spectrum of symptoms from upper limb ischemia to cerebral hypoperfusion and coronary steal syndrome (SSS)\u003csup\u003e[4, 5]\u003c/sup\u003e. Subclavian artery stenosis can be identified by measuring asymmetric blood pressure in the upper limbs or detecting a difference in systolic blood pressure greater than 15 mmHg between the two arms\u003csup\u003e[6]\u003c/sup\u003e. Common risk factors for PAD typically include smoking, hypertension, diabetes, and hyperlipidemia\u003csup\u003e[7]\u003c/sup\u003e. However, the clinical presentation can vary based on anatomical factors, including the severity and origin of stenosis and the presence of arterial disease in other regions. These manifestations encompass asymmetry in blood pressure within the upper extremities, the absence or weakening of pulses in the axillary, brachial, radial, or ulnar arteries, and the presence of finger ulcers or gangrene\u003csup\u003e[8]\u003c/sup\u003e. In this case, the patient presented with a minimum of two risk factors, notably hypertension and diabetes mellitus. Additionally, an asymmetry was observed in bilateral arterial pulsations during the radial artery puncture, although no ulcers or gangrene were evident in the fingers.\u003c/p\u003e\n\u003cp\u003eSubclavian artery stenosis typically presents asymptomatically in the majority of patients as the disease advances gradually, with symptoms emerging only when the lumen diameter narrows to less than 50%\u003csup\u003e[9]\u003c/sup\u003e. Consequently, a heightened suspicion of subclavian artery stenosis is essential when encountering bilateral blood pressure asymmetry in a patient. The patient\u0026apos;s head CT showed lacunar cerebral infarction in the bilateral basal ganglia and demyelination changes in the white matter. Additionally, the patient expressed discomfort during activities, notably dizziness, which could be attributed to inadequate blood supply in the brain artery (vertebrobasilar artery) or compromised blood flow in the upper limb artery due to the subclavian steal phenomenon\u003csup\u003e[10]\u003c/sup\u003e. The pathophysiology involves the redirection of blood flow from the brain to the arm, resulting in symptoms of vertebrobasilar insufficiency, particularly exacerbated by vigorous arm movements or sudden sharp head rotations towards the affected side. These symptoms result from two mechanisms: 1) Blood flow diversion by the arm from the vertebrobasilar region and 2) Inadequate blood supply due to subclavian artery stenosis\u003csup\u003e[11]\u003c/sup\u003e. The main symptoms include dizziness, vertigo, syncope, ataxia, imbalance, falls, diplopia, nystagmus, hemianopsia, blurred vision, tinnitus, hearing loss, bilateral arm muscle weakness, and others\u003csup\u003e[12]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe patient\u0026apos;s electrocardiogram displayed low and inverted T waves in leads II, III, avF, and V3-V9, while the echocardiogram revealed left atrial enlargement and thickening of the basal ventricular septum. These findings indicate the presence of myocardial ischemia and associated structural changes, potentially linked to subclavian artery stenosis. Typically, the proximal end of the left internal mammary artery (LIMA) connects to the left subclavian artery\u003csup\u003e[13]\u003c/sup\u003e. After resection, its distal end is anastomosed to the compromised epicardial coronary artery. Proximal stenosis of the left subclavian artery leads to a reversal of blood flow from the heart towards the left internal mammary artery to maintain adequate blood perfusion in the left upper extremity. This phenomenon is recognized as coronary-subclavian steal syndrome (CSSS)\u003csup\u003e[14]\u003c/sup\u003e. CSSS can result in myocardial ischemia, angina pectoris, acute coronary syndrome, heart failure, and severe ventricular arrhythmias\u003csup\u003e[15, 16]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003ePerioperative blood pressure management is pivotal in patient care, ensuring optimal perfusion of vital organs by maintaining an ideal blood pressure level. Adequate blood pressure management in patients with subclavian artery pathology is critical, as inaccurate blood pressure readings can mislead anesthesiologists and result in delayed interventions. This situation can lead to prolonged periods of hypotension and hypoperfusion during the perioperative phase, increasing the risk of stroke and multiple organ failure for the patients. Moreover, inappropriate interventions, including the excessive use of vasoactive medications, can further strain the cardiovascular and neurological systems, ultimately contributing to a poorer prognosis. Given the variability in bilateral upper limb SBP differences among patients with subclavian artery stenosis, it is essential to establish personalized blood pressure management targets. Typically, in patients with subclavian artery stenosis, bilateral brachial artery blood pressure is assessed using a cuff, and invasive radial artery blood pressure is monitored on one side while cuff blood pressure is taken on the other\u003csup\u003e[6]\u003c/sup\u003e. Blood pressure measurements may be inaccurate due to the use of cuffs that are either too loose, too wide, or of inappropriate size. In this case, direct intravascular pressure measurement through bilaterally assessing the radial artery enables continuous, reliable, and accurate blood pressure values, serving as the gold standard for blood pressure monitoring.In addition, we found that despite the large differences between the two sides, the changes in invasive blood pressure on the left and right sides were relatively consistent (as shown in Figure 1), which indicates that dynamic measurement of bilateral invasive blood pressure is necessary. During perioperative anesthesia management, it is crucial to regulate both decreases and elevations in blood pressure, minimize sudden and extreme blood pressure fluctuations, and aim to keep blood pressure fluctuations within \u0026plusmn;20% to prevent the onset of coronary steal syndrome and stroke.\u003c/p\u003e\n\u003cp\u003eThe inter-arm blood pressure difference (IABDP) \u0026gt; 10 mm Hg suggests asymmetric stenosis in the upper arm artery, with reduced blood pressure on the stenotic side\u003csup\u003e[17]\u003c/sup\u003e; IASBPD\u0026ge;15mm Hg has high specificity and moderate sensitivity for the diagnosis of subclavian stenosis\u003csup\u003e[18]\u003c/sup\u003e. Patients with IABDP greater than 10 mmHg are more likely to develop coronary artery disease, peripheral artery stenosis, and other cardiovascular events. In addition, they have higher morbidity and mortality. For every 1 mmHg increase in IABDP, the risk of 10-year cardiovascular mortality increased by 1% to 2%\u003csup\u003e[19]\u003c/sup\u003e. Min Li et al. showed that the risk of cardiovascular death was increased by 88% in patients with IABDP\u0026ge;10mm Hg and by 93% in patients with IASBPD\u0026ge;15mm Hg\u003csup\u003e[20]\u003c/sup\u003e. The pathological foundation of IABDP lies in the asymmetrical stenosis of the bilateral subclavian artery, axillary artery, and brachial artery, which can manifest unilaterally or bilaterally. Involvement of the left subclavian artery is more common than the proper or innominate artery, with the incidence of left subclavian artery stenosis being four times that of the right subclavian artery\u003csup\u003e[2]\u003c/sup\u003e. Lower blood pressure occurs on the side of the artery with stenosis or more severe stenosis, resulting in developing IABDP. In this case, the patient presented an uncommon occurrence of bilateral subclavian artery stenosis, as depicted in Figure 3 (moderate to severe stenosis on the left side and mild to moderate on the right side). Previous studies have indicated lower blood pressure on the side with stenosis. Notably, in this case, the systolic blood pressure in the right radial artery was significantly higher than that in the left, with a substantial difference of 46\u0026plusmn;11 mmHg between the two. The siphon effect causes blood to flow from the ipsilateral vertebral artery backward into the subclavian artery, while blood from the corresponding contralateral artery flows into the distal end of the occluded artery through the communicating artery to compensate, this mechanism increases systolic blood pressure on the side with more severe stenosis. It is also worth noting that with the removal of the lower limb thrombus, the SBP Difference between the two sides decreased significantly (as shown in Figure\u0026nbsp;2). Whether the IABDP is related to the lower limb thrombosis, and whether the formation of lower limb thrombosis is related to the stenosis of the subclavian artery, is a question worthy of further investigation.\u003c/p\u003e\n\u003cp\u003eIn cases of subclavian artery stenosis, it is imperative to promptly measure the blood pressure in the extremities. In this instance, we only measured the radial artery blood pressure of both upper limbs, the main reason was that we did not know whether the patient had subclavian artery stenosis or rare bilateral subclavian artery stenosis before surgery, and the patient underwent emergency left lower limb artery incision thrombectomy, we did not have sufficient time for further diagnosis. To enhance accuracy and ensure stable blood pressure maintenance during the operation while minimizing postoperative complications, it may be helpful to us to compare the non-invasive blood pressure in the right lower limb.\u003c/p\u003e"},{"header":"Summary","content":"\u003cp\u003eSpecial attention should be given to synchronously measuring blood pressure in both upper limbs or all four limbs of patients with subclavian artery stenosis. As blood pressure is subject to dynamic changes and can vary when measured by the same individual at different times, synchronous measurements help mitigate these fluctuations, yielding more precise results. Before operation, we should actively control the patient\u0026apos;s blood pressure to normal level, avoid hemodynamic fluctuations, and reduce the occurrence of cerebrovascular accident. Limb blood pressure measurement has gained recognition for its efficacy in screening and diagnosing peripheral arterial disease. Moreover, it is increasingly significant in evaluating cardiovascular disease risk, screening subclinical atherosclerotic disease, and predicting cardiovascular events. As interest in limb blood pressure measurement grows, this straightforward and cost-effective method is expected to have a more pronounced impact on clinical practice in screening and diagnosing peripheral vascular disease and high-risk cardiovascular conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eXQ wrote the paper; WCL followed-up the patient and participated in the treatment and management of patient; HMX and DW helped to correct the article; YH conceptualized the idea and finalized the manuscript; All authors have read and approve the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCaesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). \u003c/li\u003e\n\u003cli\u003eAhmed MA, Parwani D, Mahawar A, Gorantla VR. Subclavian Artery Calcification: A Narrative Review. Cureus. 2022. 14(3): e23312.\u003c/li\u003e\n\u003cli\u003ePatel R, White CJ. Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists. Prog Cardiovasc Dis. 2021. 65: 44-48.\u003c/li\u003e\n\u003cli\u003eAn X, Dong H, Deng Y, et al. Evaluation of the role of combining inter-arm systolic pressure difference and derivatives of pulse volume recording in detecting subclavian artery stenosis. Front Cardiovasc Med. 2022. 9: 962610.\u003c/li\u003e\n\u003cli\u003eCaesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). \u003c/li\u003e\n\u003cli\u003eAdams M, Sousa CP, Duarte S, Machado H. When the Conception of Symmetry Deceives Us: A Case Report on the Perioperative Diagnosis of Subclavian Artery Stenosis. Cureus. 2023. 15(11): e48699.\u003c/li\u003e\n\u003cli\u003ePrasad A, Wassel CL, Jensky NE, Allison MA. The epidemiology of subclavian artery calcification. J Vasc Surg. 2011. 54(5): 1408-13.\u003c/li\u003e\n\u003cli\u003ePatil C, Kotamraju S, Kumar P, Kollu R, Reddy M. Right Vertebral Artery Arising From Ipsilateral Common Carotid Artery With Severe Stenosis of Ostio-proximal Segment of Aberrant Right Subclavian Artery: A Rare Life-Saving Variant. Cureus. 2022. 14(6): e25566.\u003c/li\u003e\n\u003cli\u003eCaesar-Peterson S, Bishop MA, Qaja E. StatPearls. 2024. Treasure Island (FL). \u003c/li\u003e\n\u003cli\u003eShankar Kikkeri N, Nagalli S. StatPearls. 2024. Treasure Island (FL). \u003c/li\u003e\n\u003cli\u003eZavaruev AV. [Subclavian steal syndrome]. Zh Nevrol Psikhiatr Im S S Korsakova. 2017. 117(1): 72-77.\u003c/li\u003e\n\u003cli\u003eSong D, Ireifej B, Seen T, Almas T, Sattar Y, Chadi Alraies M. Diagnosis and management of unilateral subclavian steal syndrome with bilateral carotid artery stenosis. Ann Med Surg (Lond). 2021. 68: 102597.\u003c/li\u003e\n\u003cli\u003eSteinberger J, Georgie F, Zughaib M. Coronary Subclavian Steal Syndrome in a 73-Year-Old Woman Presenting with Angiographically Confirmed Subclavian Artery Stenosis Proximal to the Left Internal Mammary. Am J Case Rep. 2022. 23: e937015.\u003c/li\u003e\n\u003cli\u003eLak HM, Shah R, Verma BR, Roselli E, Caputo F, Xu B. Coronary Subclavian Steal Syndrome: A Contemporary Review. Cardiology. 2020. 145(9): 601-607.\u003c/li\u003e\n\u003cli\u003eMandak J, Lojik M, Tuna M, Chek JL. Coronary subclavian steal syndrome causing acute myocardial infarction in a patient undergoing coronary-artery bypass grafting. Case Rep Med. 2012. 2012: 798356.\u003c/li\u003e\n\u003cli\u003eWu CH, Sung SH, Chang JC, Huang CH, Lu TM. Subclavian artery thrombosis associated with acute ST-segment elevation myocardial infarction. Ann Thorac Surg. 2009. 88(6): 2036-8.\u003c/li\u003e\n\u003cli\u003eEnglish JA, Carell ES, Guidera SA, Tripp HF. Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv. 2001. 54(1): 8-11.\u003c/li\u003e\n\u003cli\u003eAboyans V, Kamineni A, Allison MA, et al. The epidemiology of subclavian stenosis and its association with markers of subclinical atherosclerosis: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2010. 211(1): 266-70.\u003c/li\u003e\n\u003cli\u003eHeshmat-Ghahdarijani K, Ghasempour Dabaghi G, Rabiee Rad M, Bahri Najafi M. The Relation Between Inter Arm Blood Pressure Difference and Presence of Cardiovascular Disease: A Review of Current Findings. Curr Probl Cardiol. 2022. 47(11): 101087.\u003c/li\u003e\n\u003cli\u003eLi M, Fan F, Qiu L, Ma W, Zhang Y. 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J Clin Hypertens (Greenwich). 2023. 25(12): 1069-1078.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bilateral Subclavian Artery Stenosis, Emergency Thrombectomy, Peripheral Artery Disease, Perioperative Complications","lastPublishedDoi":"10.21203/rs.3.rs-4191168/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4191168/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e Bilateral subclavian artery stenosis is a rare peripheral artery disease. This case study presents a patient who underwent an emergency thrombectomy for this condition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e The diagnosis of bilateral subclavian artery stenosis was confirmed through perioperative measurement of radial arterial blood pressure in both upper limbs and postoperative examination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e The study highlights the crucial need for accurately measuring blood pressure in all limbs to prevent perioperative complications resulting from inaccurate readings, delayed interventions, or unnecessary procedures.\u003c/p\u003e","manuscriptTitle":"Anesthetic management of a patient with bilateral subclavian artery stenosis undergoing lower extremity arterial thrombectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 16:14:28","doi":"10.21203/rs.3.rs-4191168/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30d63738-8bb0-45cf-b756-df060ac63eac","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-12T11:28:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-10 16:14:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4191168","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4191168","identity":"rs-4191168","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}