Innominate steal syndrome–a hybrid approach

The innominate and subclavian arteries are the most common locations for stenotic lesions in the upper extremities.1 Innominate steal phenomenon (ISP) is a rare clinical finding, characterized by a flow inversion of a segment or the entire carotid axis, on color duplex scan (CDS), caused by a stenosis or occlusion of the innominate artery.2 Hemodynamic findings on CDS include reversed or bidirectional flow in the right vertebral artery, midsystolic deceleration or total reversed flow in any of the branches of the right carotid axis and an elevated left common carotid artery (CCA)/right CCA ratio.2,3 Unlike subclavian steal, ISP is usually symptomatic, affecting booth posterior fossa and hemispheric cortex.4