Chapter 47

### INTRODUCTION

When one discusses vascular diseases, a number of problems or situations may develop and require the patient to seek medical assistance. Most such problems may be readily recognized and many may be treated conservatively and successfully with little effort or risk. Some situations, however, may produce vague or confusing symptoms and thus may be very difficult to sort out or to diagnose. These patients may then see numerous physicians and have extensive evaluation before the correct diagnosis or therapy is appropriately delineated. Such a diagnostic and therapeutic challenge for physicians may be a patient with a steal syndrome (SS).

Patients present with the more classic, cerebral steal symptomatology in which the diagnosis was readily proven or established. We have also seen a number of individuals with vague, perplexing symptoms for evaluation and in whom eventually a steal syndrome was diagnosed. Those patients who have an established, symptomatic steal syndrome need to be provided the therapeutic options, including major invasive procedures or corrective surgery. Patients with asymptomatic incidentally encountered steal findings present a different situation. Many of these situations require little or no treatment and close periodic follow-up. Avoidance of major interventions and their potential complications may thus be minimized. The severely debilitating or acute life-threatening "steal" developments may require urgent or emergent intervention and the accompanying risk to preserve life or limb. Multiple considerations affect the ultimate therapy and prognosis for the patient (Table 47-1).

TABLE 47-1.

Steal Syndrome Considerations

### DEFINITION

What is the definition of a steal syndrome? Different authors may ascribe different definitions or characteristics to this syndrome. A simple definition might be the taking of a blood supply from its usual direction and organ to another area as a result of a change in pressure gradient. This phenomenon can then occur in a number of situations. The classic example is where an artery is obstructed and the blood flow is then reversed in a vessel taking origin distal to the obstruction. The flow then travels around the obstruction and into the distal obstructed artery to serve the tissues distal to the obstruction. This may particularly occur when a greater need is recognized distally because of increased exercise or usage.

When this occurs, the blood, which originally flows away from the vessel obstructed, now flows toward the obstructed vessel and reverses the flow of blood into the circuitous route. This then redirects blood away from the original end-organ and provides the blood and nutrients to the ischemic or needy tissues. Thus, the original end-organ may receive a smaller supply of blood or nutrients. If the patient has findings on vascular study of blood flow redirection, or reversal, and the patient is asymptomatic, the ...

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