The coronary subclavian steal syndrome: an uncommon sequel to internal mammary-coronary artery bypass surgery

Eversion Subclavian Endarterectomy and Transposition for Coronary-Subclavian Steal Syndrome in a Patient with Refractory Angina Pectoris

Late onset of angina pectoris associated with subclavian artery (SA) atherosclerotic occlusive disease is a rare and recognized cause of myocardial ischemia when the lesion is proximal to a left internal mammary artery (LIMA) to coronary bypass. The symptoms typically exacerbate by increasing the flow demand in the extremity; this phenomenon is known as late coronary-subclavian steal syndrome. We describe the case of a 66-year-old woman who underwent coronary artery bypass grafting from the LIMA to the left anterior descending coronary artery in 2000. Years later, she experienced refractory angina pectoris associated to an occlusive lesion in the proximal left SA. SA endarterectomy with eversion technique and subclavian-carotid transposition restored the antegrade flow with resolution of the symptomatology.

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.

Subclavian steal syndrome successfully treated with a novel application of embolic capture angioplasty

Subclavian artery stenosis can lead to subclavian steal syndrome. Endovascular treatment of these lesions has become the preferred modality. We describe the successful use of embolic capture angioplasty for the treatment of a patient with subclavian artery stenosis resulting in subclavian steal syndrome.

Aortoaxillary bypass during cardiac operation

AIMS

The aim of the present study was to analyze our experience in the use of the aortoaxillary bypass during cardiac operation in a limited series of patients with proximal atherosclerotic lesion of the subclavian artery combined with cardiac disease amenable to surgical treatment.

METHODS

Of 1953 consecutive patients who underwent cardiac operation at our unit between April 2009 and July 2012, nine (0.5%; four women and five men; mean age 69.0 ± 6.2 years) suffered from symptomatic occlusive disease of the subclavian artery, and underwent concomitant aortoaxillary bypass. A ring-reinforced polytetrafluoroethylene vascular graft was anastomosed to the proximal segment of the axillary artery, introduced into the pleural cavity through the first or the second intercostal space, and anastomosed to the ascending aorta. All perioperative data were collected prospectively.

RESULTS

Seven (77.8%) left and two (22.2%) right aortoaxillary bypasses were achieved. Ten concomitant cardiac operations were performed. There were no early postoperative complications related to the subclavian artery revascularization. At a mean follow-up of 27.3 ± 15.5 months, both the symptoms of the subclavian artery disease and those of the heart disease improved. High-resolution computed tomography angiography confirmed an excellent patency of the aortoaxillary bypass in all the patients but one.

CONCLUSION

Concomitant aortoaxillary bypass and cardiac operation may be an option to keep in mind for patients with coexisting subclavian artery occlusion and heart disease, after the evidence that the combined operation does not increase the risk. Attention should be paid to the course of the bypass graft toward the axillary artery.

Coronary-subclavian steal syndrome presenting with ventricular tachycardia

Coronary-subclavian steal through the left internal mammary graft is a rare cause of myocardial ischemia in patients who have had a coronary bypass surgery. We report a 70-year-old man who presented with sustained monomorphic ventricular tachycardia 5 years after the surgical creation of a left internal mammary to the left anterior descending artery. Cardiac catheterization illustrated that the left subclavian artery was occluded proximally and that the distal course was visualized by retrograde filling through the left internal mammary graft. Clinical ventricular tachycardia was reproducibly induced with a single ventricular extrastimulus, and antitachycardia pacing terminated the tachycardia. Restoration of blood flow by way of a Dacron graft placed between the descending aorta and the subclavian artery resulted in the total relief of symptoms. Ventricular tachycardia could not be induced during the control electrophysiologic study after surgical revascularization.

Coronary-subclavian steal: presentation and management: two case reports

Subclavian stenosis is a highly prevalent and underrecognized clinical entity. In patients with a history of coronary artery bypass grafting utilizing a left internal mammary artery, subclavian artery stenosis can cause coronary-subclavian steal, leading to myocardial ischemia. Traditionally, this has been treated surgically with a vascular bypass operation. Two cases of coronary-subclavian steal syndrome are presented, 1 treated percutaneously with angioplasty and stent, and 1 treated with a combined endovascular-surgical procedure.

Tc-99m tetrofosmin myocardial SPECT combined with a modified exercise protocol in an unusual case of steal phenomenon

A 61-year-old diabetic woman was referred for myocardial perfusion single photon emission computed tomographic (SPECT) imaging 4 years after coronary artery bypass grafting to the left anterior descending (LAD) artery using a left internal mammary artery (LIMA) graft. She had 3 months' angina associated with fatigue of her left upper extremity (the patient is left-handed). Stress myocardial imaging using a Bruce protocol did not exhibit significant myocardial ischemia, but because of her typical angina symptoms, she underwent repeat stress myocardial imaging in combination with exercise of her left arm. During the aforementioned modified stress protocol, the patient reported angina, and radionuclide perfusion imaging showed extensive myocardial ischemia. The patient underwent coronary angiography and arteriography of the left subclavian artery, which revealed severe stenosis before the origin of the LIMA, resulting in reversed blood flow from the LAD artery through the LIMA graft to the left subclavian artery.

Prevalence of subclavian artery stenosis in patients with peripheral vascular disease

Internal mammary arteries (IMA) as conduits in coronary artery bypass grafting are superior to saphenous vein grafts. If there is subclavian artery stenosis (SAS) proximal to the IMA graft, impairment of flow to the IMA may occur. If the stenosis is severe, retrograde flow from the grafted coronary artery to the brachial artery may lead to angina. Following the identification of 2 cases of angina secondary to subclavian artery stenosis at their institution, the authors prospectively performed arch angiography in a cohort of patients with manifestations of peripheral vascular disease undergoing diagnostic coronary angiography to assess the prevalence of subclavian stenosis. Fifty-two patients were enrolled in the protocol, with 48 patients having technically acceptable studies. Of these 48, 41.6% had measurable stenosis of at least one of the brachiocephalic arteries, with 35% of patients with at least a 30% stenosis of the left subclavian artery and 18.7% with more than 50% stenosis. They conclude that patients with significant peripheral vascular disease undergoing coronary angiography who are potential candidates for revascularization may benefit from arch angiography as part of their initial evaluation.

Coronary bypass surgery using the internal thoracic artery after reconstruction of occluded subclavian artery

We present two cases with an occluded left subclavian artery requiring coronary artery bypass grafting. A preoperative angiogram confirmed that the subclavian artery, including the internal thoracic artery distal from the occlusion, was thoroughly intact, in both cases. Immediately after reconstructing the subclavian artery using an aortoaxillary bypass with an 8 mm ring-reinforced polytetrafluoroethylene graft, each patient underwent double coronary artery bypass grafting using the affected left internal thoracic artery with either the right internal thoracic artery or a saphenous vein in the same anesthetic setting. Symptomatic relief was excellent. In both cases, a postoperative angiographic study showed good function of the left internal thoracic artery graft supplying blood to the coronary artery through the aortoaxillary bypass graft.

Coronary steal by IMA bypass graft side-branches: a novel therapeutic use of a new detachable embolization coil

Coronary artery steal syndromes following coronary artery bypass grafting (CAB) may occur as a result of the presence of large side-branches arising from the internal mammary artery (IMA). We report the first successful deployment of a new detachable vascular embolization coil device to occlude the IMA side-branches in two patients. Optimal positioning is easily obtained with the unique operator-controlled, safety-release protected mechanism of this device. Complete retraction is possible, with safe and efficient removal of the coil even after deployment. This feature was appreciated during one procedure in which the initially selected coil was found to be oversized, requiring immediate removal. Acute thrombo-occlusion of the IMA side-branches in both patients was observed. We conclude that IMA bypass graft side-branches causing coronary steal can be safely and effectively occluded using this new technique. However, due to observed delayed partial recanalization noted on distant follow-up angiography, we recommend placement of multiple coils at the time of initial embolization.

Simultaneous subclavian artery reconstruction in coronary artery bypass grafting

BACKGROUND

Subclavian artery occlusive lesion, although rare, is sufficiently important to consider before coronary artery bypass grafting because it can cause not only symptoms of the lesion per se, but also the postoperative coronary-subclavian steal phenomenon.

METHODS

Four patients undergoing coronary artery bypass grafting received simultaneous reconstruction of the subclavian artery. During aortic cross-clamping, an 8-mm ring-reinforced polytetrafluoroethylene graft was attached to the aorta perpendicularly. The prosthetic graft was led to the proximal segment of the axillary artery through the second intercostal space and anastomosed to the inferior surface of the artery.

RESULTS

Three patients received unilateral reconstruction of the subclavian artery, whereas another received bilateral reconstruction. There were no complications related to the subclavian reconstruction procedure. Post-operative angiograms revealed excellent patency of the prosthetic grafts. All of the patients have been asymptomatic with follow-up periods ranging from 9 to 50 months.

CONCLUSIONS

To perform simultaneous subclavian artery reconstruction along with coronary artery bypass grafting, the aortoaxillary bypass procedure using an 8-mm polytetrafluoroethylene graft may be the method of choice because it has lower potential for complications and is less technically demanding.