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Innominate Artery Occlusive Disease: Sonographic Findings

Edward G. Grant1, Suzie M. El-Saden2, Beatrice L. Madrazo3, J. Dennis Baker4 and Mark A. Kliewer5

1 Department of Radiology, University of Southern California Keck School of Medicine, University Hospital, 1500 San Pablo St., Los Angeles, CA 90033.
2 Department of Radiology, West Los Angeles VA Medical Center, Los Angeles, CA.
3 University of Miami Medical School, Miami, FL.
4 Department of Vascular Surgery, West Los Angeles VA Medical Center, Los Angeles, CA.
5 University of Wisconsin School of Medicine, Madison, WI.


Figure 1
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  		Fig. 1 —Schematic drawing shows location of lesion in right-sided subclavian steal syndrome (black) and innominate artery disease (red). Note that innominate lesion lies proximal to common carotid artery, whereas lesion in subclavian steal occurs between common carotid and vertebral artery origins.

 

Figure 2
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  		Fig. 2A —Vertebral artery waveforms in patients with innominate artery disease. 64-year-old man with history of dizziness. There is retrograde flow throughout cardiac cycle. Note abundant diastolic flow. VERT = vertebral artery.

 

Figure 3
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  		Fig. 2B —Vertebral artery waveforms in patients with innominate artery disease. 52-year-old man with dizziness. There is retrograde vertebral artery flow. Note that, in this case, display has been inverted. Unlike patient in A, there is no flow in diastole.

 

Figure 4
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  		Fig. 3A —Effects of provocative maneuvers on flow in vertebral artery (A) and internal carotid artery (ICA) (B) in 72-year-old asymptomatic man with innominate artery stenosis. Vertebral artery spectral waveform image initially shows marked midsystolic deceleration (straight arrow). Note sharp peak immediately before deceleration (arrowhead) and return of forward flow in diastole. With release of blood pressure cuff after 3 min of ischemia (curved arrow), flow reverses throughout cardiac cycle.

 

Figure 5
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  		Fig. 3B —Effects of provocative maneuvers on flow in vertebral artery (A) and internal carotid artery (ICA) (B) in 72-year-old asymptomatic man with innominate artery stenosis. Waveform from right ICA is initially dampened and shows typical systolic spike followed by a subtle midsystolic deceleration. Flow never crosses baseline. After release of blood pressure cuff, there is minimal change, with mild generalized decrease in velocity during first cardiac cycle, but no overall change in waveform appearance.

 

Figure 6
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  		Fig. 4A —Innominate steal in 56-year-old woman with Takayasu's arteritis and occluded innominate artery. Color Doppler image of right common carotid artery (CCA) shows reversal of flow direction. Note that carotid flow is displayed in same color as adjacent jugular vein. IJ = internal jugular vein.

 

Figure 7
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  		Fig. 4B —Innominate steal in 56-year-old woman with Takayasu's arteritis and occluded innominate artery. Spectral Doppler images show reversed flow in all three portions of right carotid system (CCA, external carotid artery [ECA], and internal carotid artery [ICA]). Note low-resistance flow pattern in ECA and minimal diastolic flow in ICA.

 

Figure 8
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  		Fig. 4C —Innominate steal in 56-year-old woman with Takayasu's arteritis and occluded innominate artery. Spectral Doppler images show reversed flow in all three portions of right carotid system (CCA, external carotid artery [ECA], and internal carotid artery [ICA]). Note low-resistance flow pattern in ECA and minimal diastolic flow in ICA.

 

Figure 9
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  		Fig. 4D —Innominate steal in 56-year-old woman with Takayasu's arteritis and occluded innominate artery. Spectral Doppler images show reversed flow in all three portions of right carotid system (CCA, external carotid artery [ECA], and internal carotid artery [ICA]). Note low-resistance flow pattern in ECA and minimal diastolic flow in ICA.

 

Figure 10
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  		Fig. 4E —Innominate steal in 56-year-old woman with Takayasu's arteritis and occluded innominate artery. MR angiography image reveals complete occlusion of innominate artery immediately beyond its origin.

 

Figure 11
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  		Fig. 5A —57-year-old man with right-sided amaurosis fugax and innominate artery disease. Waveform from right common carotid artery (CCA) shows unusual squared-off appearance. On close inspection, one can identify systolic spikes (arrowheads) and midsystolic deceleration (arrows) in several cardiac cycles.

 

Figure 12
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  		Fig. 5B —57-year-old man with right-sided amaurosis fugax and innominate artery disease. Spectral waveforms from right internal carotid artery show abnormalities typical of innominate artery disease. Note sharp systolic spikes (arrowhead) and marked midsystolic deceleration (arrow) with flow to baseline or below during several cardiac cycles. ICA = internal carotid artery, PROX = proximal.

 

Figure 13
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  		Fig. 5C —57-year-old man with right-sided amaurosis fugax and innominate artery disease. Spectral patterns from right external carotid artery do not clearly show systolic spike or midsystolic deceleration. Waveform, however, is remarkable for large amount of diastolic flow. Resistive index is 0.52. Temporal tap was performed, as evidenced by transient oscillations (OSC), to further confirm that this vessel was external carotid artery (ECA).

 

Figure 14
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  		Fig. 5D —57-year-old man with right-sided amaurosis fugax and innominate artery disease. Anteroposterior view from conventional digital subtraction angiogram shows focal eccentric high-grade innominate artery stenosis.

 

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