Concomitant occlusive disease of the coronary arteries and great vessels

Multimodality imaging in subclavian steal syndrome

Subclavian steal syndrome is a rare vascular cause of recurrent effort-related syncope events, affecting ~2% of the general population. Here, we report a case of a 64-year-old male who was hospitalized because of recurrent effort-related syncope events. Physical examination revealed several characteristic clinical clues for subclavian steal syndrome. Indeed, through the use of multimodality imaging, the diagnosis was established. We demonstrate that the combination of history taking, thorough physical exam and subsequent imaging studies can establish a relatively rare diagnosis of recurrent syncope.

Coronary subclavian steal syndrome

PURPOSE OF REVIEW

Coronary subclavian steal syndrome (CSSS) is the reversal of blood flow in an internal mammary artery bypass graft that results in coronary ischemia. CSSS is an uncommon but treatable cause of coronary ischemia. In this review, we highlight the historical background and epidemiology of CSSS, common clinical presentations, diagnosis of CSSS and management strategies for relieving ischemia. We also present a case report to illustrate the complexity of CSSS and percutaneous management using current technology.

RECENT FINDINGS

Most commonly, CSSS results from atherosclerotic stenosis of the subclavian artery and occurs in 2.5-4.5% of patients referred for coronary artery bypass grafting (CABG). All patients referred for CABG should have bilateral noninvasive brachial blood pressures checked to screen for the underlying subclavian stenosis. A review of 98 case reports with 128 patients demonstrated a diverse clinical presentation of CSSS, including acute myocardial infarction, unstable angina and acute systolic heart failure. Resolution of CSSS symptoms has been reported with both surgical and percutaneous revascularization. Long-term patency with either revascularization strategy is excellent. Percutaneous revascularization is largely considered the first-line therapy for CSSS and can be safely performed prior to CABG to prevent CSSS.

SUMMARY

CSSS should be suspected in patients presenting with angina, heart failure or myocardial infarction after CABG. Successful amelioration of CSSS symptoms can be safely and effectively performed via percutaneous revascularization.

Prevalence of concomitant atherosclerotic arterial diseases in patients with significant cervical carotid artery stenosis in Taiwan

BACKGROUND

Atherosclerotic stenosis of extracranial carotid arteries is an important cause of ischemic stroke in Taiwan, an ethnic Chinese population. Concurrent atherosclerotic arterial disease is an important issue in the management of patients with carotid stenosis, but its prevalence and extent are unknown.

METHODS

One hundred and sixty-three consecutive patients with angiographically proven significant cervical carotid artery stenosis (>or=50% stenosis) were enrolled in this study. Angiography was done to document concurrent coronary, renal, and limb artery stenosis. Clinical symptoms and signs were also correlated with the angiographic findings.

RESULTS

One or more significant concurrent arterial stenotic disease was found in 73% of the patients. The most frequent were coronary artery disease, found in 68% of the patients, while renal artery stenosis and limb artery stenosis were found in 20% and 21% of the patients, respectively. Age, diabetes, history of angina pectoris, intermittent claudication, and asymmetric arm blood pressures were significantly associated with the presence of concurrent arterial stenosis. However, 41% of the patients with concurrent coronary artery disease did not have any clinical symptoms or history of myocardial infarction.

CONCLUSIONS

Our data indicated that concurrent advanced and extensive arterial disease is common in patients with significant cervical carotid stenosis, and also suggest the importance of global evaluation of systemic atherosclerosis in these patients to achieve optimal management.

Myocardial thievery: the coronary-subclavian steal syndrome

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.

Concomitant Brachiocephalic and Coronary Artery Disease: Outcome and Decision Analysis

BACKGROUND

In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit.

METHODS

Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only.

RESULTS

All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 +/- 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 +/- 10.5%, stroke 82.1 +/- 9.9%, redo coronary artery bypass grafting 95.8 +/- 4.1%, other vascular operation 82.2 +/- 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% +/- 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency.

CONCLUSIONS

Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.

Brachiocephalic reconstruction I: Operative and long-term results for complex disease

OBJECTIVES

Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit.

METHODS

Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%).

RESULTS

No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%.

CONCLUSIONS

Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.

Concomitant subclavian and coronary artery disease

BACKGROUND

Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia.

METHODS

We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal.

RESULTS

All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years).

CONCLUSIONS

Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

Coronary and major vascular disease: aggressive screening and priority-based therapy

It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.

Innominate artery reconstruction: over 3 decades of experience

SUMMARY BACKGROUND DATA

Symptomatic atherosclerotic occlusive disease of the innominate artery is a threatening disease pattern that offers a major challenge in achieving definitive surgical repair. To assess the evolution of treatment strategies and their outcomes for this disease, the authors undertook a review of the cumulative experience for more than 3 decades at one institution.

METHODS

Between 1960 and 1997, 94 patients (mean age, 62 years) underwent direct innominate artery revascularization for occlusive atherosclerotic disease to relieve neurologic (n = 85) and/or right upper extremity (n = 26) symptoms or asymptomatic critical stenosis (n = 3). The pattern of atherosclerotic involvement revealed by angiography included critical stenosis (n = 77), complete occlusion (n = 10), and moderate stenosis with plaque ulceration (n = 7). A common brachiocephalic trunk was present in five patients. Transsternal (n = 68) or transcervical (n = 4) innominate endarterectomy was performed in 72 patients and bypass grafting in 22. Forty-one patients underwent concomitant endarterectomy or bypass of innominate branches or adjacent arch vessels, and 3 had coronary bypass grafting.

RESULTS

There were three perioperative deaths (3%), all due to cardiac causes. Postoperative morbidity included four strokes (three resolved), two myocardial infarctions, two transient ischemic attacks, and one sternal dehiscence. Follow-up ranged from 8 months to 20 years. Postoperative actuarial survival rate was 96% at 1 year, 85% at 5 years, and 67% at 10 years. Freedom from recurrence requiring reoperation was 100% at 1 year, 99% at 5 years, and 97% at 10 years.

CONCLUSIONS

Innominate artery reconstruction is safe and durable when either endarterectomy or prosthetic bypass is used. The anatomic variation and disease distribution permit endarterectomy for most patients. The technique of innominate endarterectomy can be extended safely to outflow and adjacent vessels.