Vertebral artery Doppler waveform changes indicating subclavian steal physiology

OBJECTIVE. The goal of this study was to characterize and classify changes in antegrade vertebral artery waveforms that may represent the early stages of subclavian steal physiology. SUBJECTS AND METHODS. A prospective examination of waveforms from 1914 vertebral arteries produced a total of 40 that had a transient sharp decline in velocities at mid or late systole. In these patients, an ECG tracing was synchronized with the pulsed Doppler waveform, and reactive hyperemia was induced in the ipsilateral arm with a blood pressure cuff. The same protocol was performed in a control group of 52 patients with normal vertebral artery waveforms. Correlation between the waveforms and subclavian disease shown on angiography was made in 10 cases collected from the prospective study and in an additional 10 cases identified from a record search. RESULTS. Four prototypic waveforms were identified on the basis of the degree of flow deceleration in mid systole. Flow velocity at the nadir of the mid systolic notch was greater than that of the end diastole for type 1 waveforms, equal to the end diastole for type 2, at the baseline for type 3, and below the baseline for type 4. The blood pressure cuff maneuver induced a change to more abnormal waveforms in 36 of 40 patients but did not change the waveforms of the control group. The correlation between waveform type and subclavian disease was statistically significant (p = 0.03). CONCLUSION. Identifiable changes in the pulse contour of antegrade vertebral artery waveforms seem to represent the early stages of subclavian steal physiology. These changes can be organized into waveform types that indicate increasingly abnormal hemodynamics.