Diagnosis and management of the coronary-subclavian steal syndrome

Simultaneous Preoperative Brachiocephalic Angiography and Coronary Angiography to Prevent Coronary-Subclavian Steal Syndrome in Coronary Surgery Candidates

BACKGROUND

Whether or not preoperative brachiocephalic angiography with left internal mammary artery (LIMA) visualization should be performed at the time of coronary angiography in patients in whom bypass grafting using LIMA is envisaged is still debated. We sought to assess the role of the routine brachiocephalic angiography artery in preventing the coronary-subclavian steal syndrome in patients who are candidates for bypass grafting using LIMA.

METHODS

Medical records of 110 patients (mean age 69.3 +/- 8.4 years) who underwent concomitant coronary angiography and brachiocephalic arteriography between May 1998 and December 2002 were reviewed. Stenosis >50%, vessel occlusion, and aneurysm were noted as significant findings.

RESULTS

Significant findings were observed in 23/110 patients (20.9%). Five patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. During a mean follow-up of 24.7 +/- 10.7 months, only one patient developed a new subclavian artery disease after bypass grafting using LIMA, and underwent subclavian artery angioplasty. Logistic regression analysis revealed 3-vessel CAD (odds ratio (OR) 9.917 ; 95% confidence interval (CI) 2.2 to 43.8; P = .002), hypercholesterolemy (OR 2.74; CI 95% 1.05 to 7.7; P = .044), and age >65 (OR 3.55; CI 95% 2.2 to 9.2, P = .038) to be predictors of brachiocephalic disease.

CONCLUSION

This study suggests that routine angiography of the brachiocephalic arteries at the time of coronary angiography is effective in preventing coronary-subclavian steal syndrome in select patients who are candidates for bypass grafting using LIMA.

Coronary subclavian steal syndrome: non-invasive imaging and percutaneous repair

Although coronary subclavian steal syndrome (CSSS) is relatively uncommon, it is a well documented cause of graft failure in patients having undergone coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA). Here we report a case of CSSS induced by restenosis of a left subclavian artery (SCA) origin stent, identified by increased velocities within the stent and an abnormal ipsilateral vertebral artery (VA) waveform on Duplex ultrasound imaging. This was successfully treated percutaneously by re-stenting, resulting in restoration of normal SCA waveforms and velocities, and normalization of the ipsilateral VA waveform.

Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery

OBJECTIVE

To identify the incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery.

DESIGN

Prospective.

SETTING

Veterans Affairs Medical Center and university-affiliated medical center.

PARTICIPANTS

Adult patients with prior coronary artery bypass graft surgery and documented use of an internal mammary artery.

INTERVENTIONS

Bilateral simultaneous brachial blood pressures were determined noninvasively. The presumptive diagnosis of ipsilateral subclavian artery stenosis and coronary-subclavian steal syndrome was made if the systolic blood pressure differential was >20 mmHg.

MEASUREMENTS AND MAIN RESULTS

The presumptive diagnosis of ipsilateral subclavian artery stenosis based on a blood pressure differential was made in 6 of 86 (5%) patients screened. The diagnosis of coronary-subclavian steal syndrome was confirmed at cardiac catheterization by observing retrograde internal mammary artery flow in 3 patients or lack of internal mammary artery flow in 1 patient (3.4%). All 4 patients with angiographic confirmation had either angina or silent ischemia. Three patients had successful carotid subclavian bypass, and 1 patient refused surgery. Two patients had no evidence of myocardial ischemia and underwent their planned procedure without incident.

CONCLUSION

Coronary-subclavian steal syndrome occurs with relative frequency in noncardiac surgery patients with prior coronary artery bypass graft surgery using internal mammary artery conduits. Bilateral blood pressure measurements should be routinely performed during the preoperative evaluation. A pressure differential >20 mmHg should suggest the possibility of coronary-subclavian steal syndrome.

Arterial reconstruction for subclavian obstructive disease: a comparison of extrathoracic procedures

OBJECTIVES

Comparison of the immediate and long-term results of three different extrathoracic arterial reconstruction procedures for subclavian obstructive disease.

DESIGN

Retrospective analysis of 51 extrathoracic subclavian artery reconstructions in 49 patients performed in a single centre over an 18-year period (mean follow-up 64 months, range 3-192).

METHODS

Carotid-subclavian bypass (CSB, n = 21), subclavian-carotid transposition (SCT, n = 21) and subclavian-subclavian or axillo-axillary cross-over bypass (COB, n = 9) was performed. Upper extremity ischaemic complaints were present in 45/49 patients (92%) and vertebrobasilar insufficiency in 25/49 patients (51%). Symptom relief, improvement of haemodynamic parameters and graft patency were compared.

RESULTS

Operation time was significantly shorter (p < 0.001, t-test) in SCT (80 +/- 5 min) compared to CSB (112 +/- 7 min) and COB (116 +/- 6 min). Symptom relief and improvement of haemodynamic parameters were similar for all groups. There were no differences in morbidity rate and there was no mortality. The cumulative patency of SCT was significantly better with 100% at 2, 5 and 10 years postoperatively compared to CSB (75.6%, 62.6% and 52.2%, respectively) (p < 0.005, log-rank test) and COB (76.5%, 63.7% and 63.7%, respectively) (p < 0.02, log-rank test). There was a tendency for a better patency in prosthetic grafts as compared to autologous vein grafts in CSB (NS, log-rank test).

CONCLUSIONS

Satisfactory immediate and long-term results were obtained with all of the above techniques. When technically feasible, SCT is the procedure of choice for extrathoracic arterial reconstruction in subclavian obstructive disease.

Use of angioplasty in the prevention and treatment of coronary--subclavian steal syndrome

PURPOSE

The coronary-subclavian artery steal (CSS) syndrome is caused by critical stenosis in the subclavian artery proximal to a bypass graft from the internal mammary artery (IMA) to the coronary artery. The stenosis results in retrograde flow in the IMA and steal from the coronary artery.

PATIENTS AND METHODS

Percutaneous transluminal angioplasty (PTA) was performed in eight patients (five men, three women). In four patients (group 1), coronary ischemia had developed 0.5-70 months (mean, 31 months) after IMA-to-coronary artery bypass surgery. These four patients (mean age, 58 years; range, 44-68 years) underwent PTA of a single area of focal subclavian stenosis to treat CSS. In four other patients (group 2), atherosclerotic subclavian stenosis had developed proximal to a donor IMA before planned bypass surgery. These patients (mean age, 53 years; range, 50-57 years) underwent PTA of a single focal subclavian stenosis to prevent CSS.

RESULTS

Group 1 patients were free of myocardial ischemia at follow-up (mean follow-up, 39.0 months; range, 14-101 months). Three of four patients in group 2 underwent coronary artery bypass grafting with the ipsilateral IMA following PTA of the subclavian stenosis; they were free of angina at follow-up (mean follow-up, 14 months; range, 10-18 months).

CONCLUSION

PTA is a safe and efficacious short-term method for prevention and treatment of CSS syndrome.

Coronary-subclavian steal syndrome: report of five cases

The internal mammary artery (IMA) is the conduit of choice for cardiac revascularization. The phenomenon of retrograde flow in this graft secondary to proximal subclavian artery stenosis is an infrequent but increasingly recognized clinical entity and has been termed the "coronary-subclavian steal syndrome." We report on five patients with this syndrome. All were men. The average age was 65 years (range 56 to 68 years). The mean interval from coronary bypass to presentation was 7.8 years (range 1 month to 18 years). Three patients presented with unstable angina and one with congestive heart failure. One patient was asymptomatic from a cardiac standpoint. The mean arm systolic blood pressure differential was 45 mm Hg (range 30 to 60 mm Hg). Each patient underwent cardiac catheterization, and retrograde IMA flow was demonstrated in 100%. Arteriography confirmed the presence of a proximal high-grade (> 75%) subclavian stenosis in all patients. Stress thallium scanning was performed in two patients and demonstrated anterolateral ischemia in both. Operative intervention in four patients consisted of a left carotid-subclavian bypass using an 8 mm synthetic graft. There was no perioperative morbidity or mortality. Postoperative thallium scanning revealed resolution of the ischemic process. The average length of follow-up was 20 months (range 12 to 25 months) with all patients remaining asymptomatic. The one patient who refused surgery died at 12 months. When IMA grafting is contemplated, proximal subclavian stenosis should be suspected if there is > 20 mm Hg systolic pressure differential between the arms.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the coronary-subclavian steal syndrome with balloon angioplasty. A case report and review of the literature

A fifty-two-year-old woman with angina pectoris due to coronary-subclavian steal syndrome through a left internal mammary artery graft placed distal to a left anterior descending artery stenosis is presented. Retrograde flow through the mammary artery graft due to severe left subclavian stenosis was observed angiographically. Accordingly, left subclavian balloon angioplasty was performed, restoring normal antegrade flow through the internal mammary artery graft and resulting in resolution of the patient's symptoms. The patient was subsequently discharged with no evidence of angina. Carotid-subclavian bypass surgery was avoided, reducing patient discomfort, procedural risk, and expense.

Coronary-subclavian steal: an unusual cause of angina pectoris after successful internal mammary-coronary artery bypass grafting

Coronary-subclavian steal syndrome is a rare cause of angina pectoris after bypass grafting using the internal mammary artery. We report the 11th case in the literature and review the pathophysiology and treatment of this disorder. We also review appropriate screening for this possibly increasing, yet preventable disorder.