Response to determining functional significance of subclavian artery stenosis using exercise thallium-201 stress imaging.

To the Editor: The functional significance of subclavian artery stenosis is easily gauged by history and physical examination, and I was therefore surprised to see the recommendations in this article for using exercise thallium-201 stress imaging. (1) This is carrying the situation a bit too far. The case report of the lady in this article clearly shows that she had left arm claudication related to her subclavian lesion. The article even goes on to state that with the use of an ergometer for exercise for nearly 3 minutes, the patient had left arm pain. The injection of thallium to confirm the findings, in my view, was expensive and unnecessary. She had an excellent result from left subclavian angioplasty with, as the article states, complete resolution of her symptoms. Therefore, a second follow-up thallium image was again expensive and unnecessary.

Vascular surgeons have known for years that a simple history of upper extremity claudication combined with the finding of a subclavian bruit in the supraclavicular fossa and a diminished blood pressure in the affected arm are all that is needed to make the diagnosis of clinically significant claudication related to subclavian stenosis. The addition of thallium stress imaging is expensive and totally uncalled for. If I were the patient or her insurance carrier, I would demand a refund for the two unnecessary thallium scans.

Also noted is the mislabeling of the narrative for Figure 1 and Figure 2 in the article. Figure 1 states that this is a coronary angiogram showing left subclavian stenosis, and as anyone with vascular experience knows, this is a selective left subclavian angiogram and not a coronary angiogram showing the lesion.

On the one hand, this article serves to educate practitioners about subclavian stenosis and the relatively infrequent cerebral or upper extremity symptoms that it causes. However your readers should not take away the idea that symptomatic subclavian stenosis requires a thallium scan to determine clinical significance. History and physical examination is a much simpler and more cost-effective way to determine the significance of a subclavian arterial stenosis.

Steve Powell, MD

Professor of Surgery

Section of Vascular Surgery

East Carolina University School of Medicine

Greenville, NC

Reference

1. Wasson S, Bedi S, Singh S. Determining Functional Significance of Subclavian Artery Stenosis Using Exercise Thallium-201 Stress Imaging. South Med J 2005;98:559-560.

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