subclavian artery stenosis or occlusion has a low prevalence ( 1.9% ) and is asymptomatic in most cases .
not all symptomatic patients require treatment . similar to the treatment of peripheral arterial disease in the lower limb ( tasc ii )
, we would expect endovascular revascularisation to be the preferable treatment option in subclavian artery lesions . however , even for large centers , it is difficult to compare results of patients with subclavian artery stenosis treated in a uniform way .
we present a case report of a patient with upper left limb ischemia caused by subclavian artery stenosis after repetitive left clavicula trauma , treated in different ways . in the discussion we give a brief systematic review of the open and endovascular treatment options with short- and long - term patency rates and possible complications . in this way
in may 2009 , a 43-year old male patient was referred to our department with ischemic symptoms ( pulseless , palor and rest pain ) of the left hand during rehabilitation .
four months prior to referral to our department , he had presented to the emergency department with a midclavicular fracture on the left side after a fall .
digital subtraction angiography ( dsa ) confirmed total occlusion of the left subclavian artery , starting after the origin of the left vertebral artery , with good collateral circulation but with slow arterial flow to the left arm ( fig .
a left carotid - subclavian bypass was performed using a six - millimeter ptfe vascular graft prosthesis ( maquet cardiovascular , rastatt , germany ) .
the postoperative course was uncomplicated and the patient was prescribed dipyridamole 150  mg twice daily and acetylsalicylic acid 500  mg once daily .
two and a half years later , in january 2012 , the patient presented with recurrence of the ischemic symptoms and with occlusion of the carotid subclavian bypass on dsa .
subsequently , denudation of the brachial artery was performed with successful recanalisation of the left subclavian artery using an opta pro 6  mm    40  mm balloon ( cordis , johnson&johnson , bridgewater , new jersey , usa ) and a viabahn 7  mm    100  mm endoprosthesis ( w.l .
dipyridamole and acetylsalicylic acid were stopped and clopidogrel 75  mg once daily was started .
nine months later , in september 2012 , the patient again presented with persistent ischemic complaints in the left arm .
dsa showed occlusion of the stent in the subclavian artery and the already known thrombosis of the carotid - subclavian bypass ( fig .
a new percutaneous transluminal angioplasty was attempted , though the procedure was neither antegradely nor retrogradely successful .
three months later , a subclavian - axillary crossover bypass was performed under general anesthesia using a seven millimeter fluoropassiv armed graft ( vascutec , terumo nv , tokyo , japan ) .
the patient was discharged on the second postoperative day . at this time , only acetylsalicylic acid 80  mg once daily was given as anticoagulation therapy .
subclavian stenosis with or without subclavian steal syndrome is relatively rare . only symptomatic patients present for treatment , which makes it difficult to estimate its incidence or prevalence rate .
if symptomatic , symptoms may vary from upper limp ischemia ( 1092% ) to signs of vertebrobasilar insufficiency ( 5184% ) , coronary - subclavian steal syndrome or future coronary bypass surgery ( 4.721% ) and less common , signs of hemispheric involvement ( 10% ) . only symptomatic patients should be treated .
our patients suffered ischemic complaints of the left upper limb either due to intima hyperplasia or extrinsic compression caused by repetitive trauma in this region .
generally , surgical decompression ( i.e. clavicula , cervical and/or first rib resection ) is advised in vascular thoracic outlet syndrome .
we did not perform first rib resection because of the high risk surgery in this region after repetitive fixation and infection .
possible constructions of extra - anatomic bypass grafting are carotid - subclavian bypass ( csb ) , carotid - subclavian transposition ( cst ) and cross over bypass ( cob ) ( axillo - axillary or subclavian  subclavian bypass ) .
there are no large studies about these procedures ( n  =  3961 ) and these studies show good long - term primary and secondary rates ranging from 82% to 100% . studies comparing csb , sct and cob show a significant shorter operating time for sct ( p  <  0.001 ) and a significant better long - term patency for sct ( 100% at 10 years versus 52.2% for csb and 63.7% for cob , p  <  0.005 ) . in these procedures a trend for better patency was seen in prosthetic graft versus autologous vein graft ( p  <  0.2 ) . in our patient
we preferred a cross - over bypass , although a valuable alternative option was a redo autologous csb .
another study comparing 20 csb with 20 cst procedures showed a patency rate of 100% for sct and 66% for csb at 6 years . in the largest study of percutaneous transluminal angioplasty ( pta ) procedures , published by henry et al .
( n  =  237 ) , primary and secondary patency at ten years were 78% and 85% .
the study showed remarkable results for a comparison between the primary and secondary patency rate without using a stent ( 67% and 76% ) versus the patency rates with a stent ( 90% and 97% ) ( p  <  0.01 ) .
patel et al . routinely performed pta procedures with stenting in patients with subclavian and innominate artery obstruction ( n  =  177 ) .
similar results were found in this study with a primary patency rate at five years of 84% and a secondary patency rate at four years of 98% .
it is difficult to compare pta with open extra - anatomic procedures because subclavian artery stenosis requiring treatment rarely occurs .
moreover , comparisons are further complicated by the heterogeneity of treatment options and material used .
they compared findings of 51 patients who underwent csb for subclavian disease with those of 121 patients who underwent pta with or without stenting .
a significant better primary patency rate was seen in the csb group versus the pta / stent group at 1 , 3 and 5 years , 100% , 98% and 96% versus 93% , 78% and 70% respectively ( p  <  0.0001 ) .
although pta / stent is a minimally invasive technique , a comparable complication rate is seen in the pta / stent group ( 2.914.9% ) versus the bypass group ( 5.914.2% ) .
our patient underwent an uncomplicated postoperative course and is still doing well with a patent bypass eleven months after the last surgical treatment .
subclavian artery stenosis is a rare condition causing symptoms in only a minority of patients .
studies comparing extra - anatomic bypass with pta / stenting show different kinds of complications but a comparable complication rate .
short - term results for these groups are also comparable . however , long - term results show a better patency rate in favor of the extra - anatomic bypass .
our case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis .
this research received no specific grant from any funding agency in the public , commercial , or not - for - profit sectors .
written informed consent was obtained from the patient for publication of this case report and any accompanying figures .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
stijn schepers wrote the paper , revised the critical important intellectual content , collected the data , and surgeon for this work.key learning pointour case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis .
our case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis .
our case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis .
 introductionstenosis of the subclavian artery is uncommon and it rarely causes symptoms . only symptomatic patients should be treated.presentation of casewe report a case of chronic left upper limb ischemia caused by subclavian artery stenosis after repetitive clavicular fixation . 
 the stenosis was first treated with carotid - subclavian bypass and soon followed by angioplasty and stenting of the subclavian artery because of occlusion of the bypass . 
 finally , failure of these procedures necessitated a subclavian - axillary crossover bypass.discussionboth extra - anatomic bypass and percutaneous transluminal angioplasty are safe and effective . 
 if feasible , many authors use endovascular treatment . according to literature , extra - anatomic bypass still remains the first choice of treatment for symptomatic patients . 
 however , the introduction of routine stent implantation is equalling these results . 
 because of its lower long - term patency rate , endovascular treatment is favorable for patients at high risk.conclusionour case is a good example of difficulties involved in choosing the best treatment option for subclavian artery stenosis . 
Introduction
Presentation of case
Discussion
Conclusion
Conflicts of interest
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