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Achim A, Johnson NP, Liblik K, Burckhardt A, Krivoshei L, Leibundgut G. Coronary steal: how many thieves are out there? Eur Heart J 2023; 44:2805-2814. [PMID: 37264699 DOI: 10.1093/eurheartj/ehad327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/17/2023] [Accepted: 05/12/2023] [Indexed: 06/03/2023] Open
Abstract
The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.
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Affiliation(s)
- Alexandru Achim
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
- Cardiology Department, Heart Institute "Niculae Stancioiu", University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001, Cluj-Napoca, Romania
| | - Nils P Johnson
- Division of Cardiology, Department of Medicine, Weatherhead PET Center, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, TX, USA
| | - Kiera Liblik
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amélie Burckhardt
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Lian Krivoshei
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Gregor Leibundgut
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Butt AK, Almaddah N, Mirza QM, Ibebuogu UN. A Unique Case of STEMI STEALing the Flow. JACC Case Rep 2020; 2:2419-2423. [PMID: 34317185 PMCID: PMC8304535 DOI: 10.1016/j.jaccas.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/16/2020] [Indexed: 11/26/2022]
Abstract
We report a case of a 55-year-old woman with previous coronary artery bypass grafting. She presented with acute ST-segment elevation myocardial infarction secondary to occlusion of the proximal left subclavian artery causing reduced flow in the left internal mammary artery to left anterior descending artery graft. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Asra Khalid Butt
- Department of Internal Medicine, University of Tennessee School of Medicine, Memphis, Tennessee, USA
| | - Nureddin Almaddah
- Section of Cardiology, University of Tennessee School of Medicine, Memphis, Tennessee, USA
| | - Qasim M Mirza
- Section of Pulmonary & Critical Care Medicine, University of Tennessee School of Medicine, Memphis, Tennessee, USA
| | - Uzoma N Ibebuogu
- Section of Cardiology, University of Tennessee School of Medicine, Memphis, Tennessee, USA
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Xenogiannis I, Tajti P, Hall AB, Alaswad K, Rinfret S, Nicholson W, Karmpaliotis D, Mashayekhi K, Furkalo S, Cavalcante JL, Burke MN, Brilakis ES. Update on Cardiac Catheterization in Patients With Prior Coronary Artery Bypass Graft Surgery. JACC Cardiovasc Interv 2019; 12:1635-1649. [DOI: 10.1016/j.jcin.2019.04.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 01/30/2023]
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Coceani M, Sbrana F, Ciardetti M, Pino BD, Palmieri C, Berti S, Giannoni A, Emdin M, Sampietro T. High-risk NSTEMI due to Subclavian Artery Atherothrombosis in a Prior Coronary Artery Bypass Graft Patient. J Cardiovasc Echogr 2019; 29:86-87. [PMID: 31392128 PMCID: PMC6657466 DOI: 10.4103/jcecho.jcecho_15_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Michele Coceani
- Division of Interventional Cardiology, Fondazione Toscana Gabriele Monasterio, Pisa and Massa, Pisa, Italy
| | - Francesco Sbrana
- Lipoapheresis and Inherited Dyslipidemias Center, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Ciardetti
- Division of Interventional Cardiology, Fondazione Toscana Gabriele Monasterio, Pisa and Massa, Pisa, Italy
| | - Beatrice Dal Pino
- Lipoapheresis and Inherited Dyslipidemias Center, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Cataldo Palmieri
- Division of Interventional Cardiology, Fondazione Toscana Gabriele Monasterio, Pisa and Massa, Pisa, Italy
| | - Sergio Berti
- Division of Interventional Cardiology, Fondazione Toscana Gabriele Monasterio, Pisa and Massa, Pisa, Italy
| | - Alberto Giannoni
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Tiziana Sampietro
- Lipoapheresis and Inherited Dyslipidemias Center, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Cua B, Mamdani N, Halpin D, Jhamnani S, Jayasuriya S, Mena-Hurtado C. Review of coronary subclavian steal syndrome. J Cardiol 2017; 70:432-437. [PMID: 28416323 DOI: 10.1016/j.jjcc.2017.02.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/01/2017] [Accepted: 02/17/2017] [Indexed: 11/25/2022]
Abstract
The clinical benefits of using the left internal mammary artery (LIMA) to bypass the left anterior descending artery are well established making it the most frequently used conduit for coronary artery bypass surgery (CABG). Coronary subclavian steal syndrome (CSSS) occurs during left arm exertion when (1) the LIMA is used during bypass surgery and (2) there is a high grade (≥75%) left subclavian artery stenosis or occlusion proximal to the ostia of the LIMA resulting in "stealing" of the myocardial blood supply via retrograde flow up the LIMA graft to maintain left upper extremity perfusion. Although CSSS was once thought to be a rare phenomenon, its prevalence has been underestimated and is becoming increasingly recognized as a serious threat to the success of CABG. Current guidelines are lacking on recommendations for screening of subclavian artery stenosis (SAS) pre- and post-CABG. We hope to provide an algorithm for SAS screening to prevent CSSS in internal mammary artery bypass recipients and review treatment options in the percutaneous era.
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Affiliation(s)
- Bennett Cua
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
| | - Natasha Mamdani
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Halpin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sunny Jhamnani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sasanka Jayasuriya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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Abstract
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.
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Srećković M, Jagić N, Miloradović V, Nikolić D, Pavlović M, Maksimović Srećković A. Unusual suspect-coronary subclavian steal syndrome caused severe myocardial ischemia. Bosn J Basic Med Sci 2014; 14:45-7. [PMID: 24579971 DOI: 10.17305/bjbms.2014.2296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Coronary-subclavian steal syndrome represents a reversal of blood flow in left internal mammary artery. The most common cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. We present a case of 72 years old male, who developed severe anginal and neurological complaints three years after coronary artery bypass graft surgery(CABG).
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Affiliation(s)
- Miodrag Srećković
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
| | - Nikola Jagić
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
| | - Vladimir Miloradović
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
| | - Dušan Nikolić
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
| | - Milica Pavlović
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
| | - Ana Maksimović Srećković
- Interventional Cardiology Department, Clinical Center Kragujevac, Zmaj Jovina 30, 34000 Kragujevac, Serbia
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Shinozaki N, Suzuki T, Ikari Y. Effective emergent endovascular recanalization for acute coronary syndrome with left subclavian artery occlusion in a prior coronary artery bypass graft patient. Cardiovasc Interv Ther 2014; 29:368-71. [PMID: 24399502 DOI: 10.1007/s12928-013-0242-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/27/2013] [Indexed: 11/28/2022]
Abstract
A 78-year-old female was hospitalized because of multiple bone fracture caused by falling down. She undertook coronary artery bypass graft (CABG) using left internal mammary artery (LIMA) about 10 years ago. She complained chest pain on the day of admission with hypotension. Emergent angiogram revealed total occlusion of left subclavian artery (SCA). We re-canalized left SCA with stent. Hemodynamics and symptom dramatically improved after the procedure. Acute coronary syndrome due to SCA occlusion after CABG using LIMA was rare, but we have to consider the possibility. Endovascular therapy to SCA lesion might be a proper strategy for these cases.
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Affiliation(s)
- Norihiko Shinozaki
- Department of Cardiology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, Japan,
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Mangialavori G, Ballo P, Michelagnoli S, Ercolini L, Barbanti E, Passuello F, Abbondanti A, Consoli L, Chechi T, Fibbi V, Nannini M, Chiodi L, Zuppiroli A. Subclavian steal syndrome presenting as recurrent pulmonary oedema associated with acute left ventricular diastolic dysfunction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2012; 14:45-8. [PMID: 23036888 DOI: 10.1016/j.carrev.2012.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 08/21/2012] [Accepted: 08/27/2012] [Indexed: 11/25/2022]
Abstract
Subclavian steal syndrome typically presents as angina in patients with internal mammary artery grafts. Atypical clinical presentations have been rarely described. We report an unusual case of subclavian steal syndrome presenting as pulmonary oedema with acute left ventricular diastolic dysfunction and preserved ejection fraction in a patient with internal mammary artery graft and severe stenosis of the proximal left subclavian artery. After successful angioplasty and stenting of subclavian artery, the patient remained asymptomatic for six months, but then experienced acute diastolic dysfunction and recurrent pulmonary oedema associated with critical subclavian in-stent restenosis with stent deformation. This report points out that, in patients with internal mammary-to-LAD grafts, subclavian steal syndrome may present as acute left ventricular diastolic dysfunction and pulmonary oedema even in the presence of normal ejection fraction.
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Coronary subclavian steal syndrome causing acute myocardial infarction in a patient undergoing coronary-artery bypass grafting. Case Rep Med 2012; 2012:798356. [PMID: 22969810 PMCID: PMC3437312 DOI: 10.1155/2012/798356] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 07/31/2012] [Indexed: 11/18/2022] Open
Abstract
Coronary subclavian steal syndrome with retrograde blood flow in the left internal mammary-coronary bypass graft is a rare but severe complication of cardiac surgery. The authors present a case of a 68-year-old man after coronary-artery bypass grafting using an internal mammary artery. He had been suffering from angina pectoris for the last several years before surgery. The patient was resuscitated at home by emergency medical service because of primary ventricular fibrillation due to an acute myocardial infarction 5 years after surgery. An occlusion of the left subclavian artery with the retrograde blood flow in the left internal mammary coronary bypass was found. This could have been the cause of insufficiency in coronary blood flow and ischemia of the myocardial muscle. The subclavian artery occlusion was successfully treated with percutaneous transluminal angioplasty and implantation of 2 stents. The patient remained free of any symptoms 2 years after this procedure.
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Jung JK, Hwang SI, Lim DJ, Jeong SJ, Lim HK. Sign of decreased coronary blood flow from ST depression and PVCs during a left lower lobectomy of the lung in a patient with a left internal mammary arterial bypass graft. Korean J Anesthesiol 2011; 61:535-6. [PMID: 22220236 PMCID: PMC3249581 DOI: 10.4097/kjae.2011.61.6.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jong-Kwon Jung
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Sung-Il Hwang
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Dae-Jin Lim
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Seong-Jin Jeong
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
| | - Hyun Kyoung Lim
- Department of Anesthesiology and Pain Medicine, Inha University Hospital, Incheon, Korea
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