Coronary-subclavian steal syndrome in a hemodialysis patient, a case report and review of literature

Coronary-subclavian steal syndrome causing myocardial infarction after arteriovenous fistula creation: a case report

Coronary subclavian steal syndrome (CSSS) caused by left subclavian artery (LSA) stenosis is a rare cause of myocardial infarction in patients having coronary artery bypass grafting (CABG), and it has also been observed after an arteriovenous fistula (AVF) was made. A 79-year-old woman who had undergone CABG years earlier and an AVF creation 1 month before experienced a non-ST-elevation myocardial infarction (NSTEMI). While selective catheterization of the left internal thoracic artery graft was impossible, a computed tomography scanner showed patency of all bypasses and proximal subocclusive LSA stenosis, and the digital blood pressure measurements objectified a haemodialysis-induced distal ischaemia. LSA's angioplasty and covered stent placement were successfully performed, resulting in symptom remission. A CSSS-induced NSTEMI due to a LSA stenosis aggravated by a homolateral AVF several years after CABG has been documented only infrequently. If vascular access is required in the presence of CSSS risk factors, the contralateral upper limb should be preferred.

Management of Coronary Artery Bypass Grafting Using an Arteriovenous Fistula: An Intraoperative Change in the Preoperative Plan

Regarding coronary artery bypass grafting (CABG) in patients on hemodialysis, in situ internal thoracic artery (ITA) grafting of the left anterior descending artery (LAD) improves survival and freedom from cardiac events. Although a problem with the ITA can possibly occur, using the ITA ipsilateral to an arteriovenous fistula (AVF) in the upper extremity of patients on hemodialysis can cause coronary subclavian steal syndrome (CSSS). CSSS is a condition of myocardial ischemia caused by the diversion of blood flow from the ITA following coronary artery bypass surgery. CSSS has been reported to occur in cases of subclavian artery stenosis, AVF, and low cardiac function. A 78-year-old man with end-stage renal disease experienced angina pectoris during hemodialysis. The patient was scheduled for CABG, including anastomosis of the left internal thoracic artery (LITA) and LAD. After completion of all anastomoses, the LAD graft demonstrated retrograde blood flow, suggestive of ITA anomalies or CSSS. The LITA graft was transected at the proximal part and anastomosed to the saphenous vein graft with sufficient flow to the high lateral branch eventually.

Subclavian steal syndrome without subclavian stenosis

Subclavian steal syndrome (SSS) has been well described in the setting of subclavian stenosis. We describe an unusual case of SSS caused by a high-flow arteriovenous dialysis fistula in the absence of subclavian stenosis, provide a review of the literature, and propose that arteriovenous fistula-induced SSS is an underdiagnosed cause of syncope in this population of patients.

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.