Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?

Subclavian artery stenosis (SAS) resulting in coronary subclavian steal syndrome (CSSS) is a common but under recognized pathology following coronary artery bypass surgery (CABG). Patients with SAS may be asymptomatic due to the sub-clinical diversion of blood flow from the myocardium and retrograde blood flow during catheter angiography in the left internal mammary artery (LIMA) may be the first suggestion of CSSS. The management of SAS, causing CSSS, may rarely require acute assessment and intervention. However, full anatomical assessment of the stenosis morphology may be limited on fluoroscopy. Correction of SAS may be essential to achieve effective reperfusion therapy.

Endovascular Therapy of Symptomatic Innominate-Subclavian Arterial Occlusive Lesions

The purpose of this study was to determine the safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions by review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the innominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical examination (pulses and blood pressures) at 1, 3, 6, and then every 12 months plus an annual duplex ultrasound examination. Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48 to 89 years. Symptoms included vertebrobasilar/steal (15), claudication (6), ischemia (4), and coronary artery bypass grafting/left internal mammary artery (2). There were 7 occlusions and 20 high-grade stenoses. Access was attempted via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (10). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 occluded lesions could not be crossed owing to complete occlusion. The remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic blood pressure between upper limbs decreased from 36 mm Hg (preprocedure) to 10 mm Hg (postprocedure). There were no procedure-related complications. Mean follow-up was 18 months (range 1–62 months). One patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the percutaneous transluminal angioplasty/stent. Of the 4 successfully treated occlusions, 2 were followed up to 3 years with continued patency. Three patients developed recurrent stenoses documented by duplex examination. However, these patients remained asymptomatic and were not treated. Endovascular management of high-grade lesions of the subclavian or innominate arteries is safe and efficacious and may be considered as a first line of therapy. Continued follow-up is needed to assess long-term patency.

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.

Endovascular Stenting under Cardiac and Cerebral Protection for Subclavian Steal after Coronary Artery Bypass Grafting Due to Right Subclavian Artery Origin Stenosis

Coronary-subclavian steal (CSS) can occur after coronary artery bypass grafting (CABG) using the internal thoracic artery (ITA). Subclavian artery (SA) stenosis proximal to the ITA graft causes CSS. We describe a technique for cardiac and cerebral protection during endovascular stenting for CSS due to right SA origin stenosis after CABG. A 64-year-old man with a history of CABG using the right ITA presented with exertional right arm claudication. Angiogram showed a CSS and retrograde blood flow in the right vertebral artery (VA) due to severe stenosis of the right SA origin. Endovascular treatment of the right SA stenosis was planned. For cardiac and cerebral protection, distal balloon protection by inflating a 5.2-F occlusion balloon catheter in the SA proximal to the origin of the right VA and ITA through the right brachial artery approach and distal filter protection of the right internal carotid artery (ICA) through the left femoral artery (FA) approach were performed. Endovascular stenting for SA stenosis from the right FA approach was performed under cardiac and cerebral protection by filter-protection of the ICA and balloon-protection of the VA and ITA. Successful treatment of SA severe stenosis was achieved with no complications.

Long-term results of primary stenting for subclavian artery disease

OBJECTIVES

To evaluate initial and long-term results of endovascular therapy (EVT) for symptomatic subclavian artery (SCA) disease.

BACKGROUND

EVT for SCA disease has a similar success rate as open surgery, but the long-term patency of EVT alone is uncertain.

METHODS

We retrospectively studied 59 consecutive patients (42 males and 17 females) with 60 lesions. Mean patient age was 68 ± 10 years. Clinical symptoms were vertebrobasilar insufficiency in 21 patients (35.0%), arm claudication in 20 patients (33.3%), angina pectoris in 12 patients (20%), severe arm ischemia in 3 patients (5.0%), vascular access insufficiency in 3 patients (5.0%), and leg ischemia in 1 patient (1.7%). A total of 57 stents were implanted. All patients were followed up at 1, 3, 6, and 12 months after the procedure and annually thereafter.

RESULTS

The technical success rate was 93.3%. All patients for whom technical success was obtained received stents. There were four technical failures, all of which were owing to the failure of crossing the wire in occluded lesions. There were no procedure-related deaths. There were two stroke events (3.4%) and one embolic event (1.7%). Primary patency rates were 94.9, 90.8, and 85.8% at 1, 3, and 5 years, respectively.

CONCLUSIONS

EVT for SCA disease is an effective treatment with regard to initial success rate, clinical efficacy, and long-term primary patency. This minimally invasive procedure is appropriate as the treatment of first choice for proximal subclavian arterial obstructive disease.

Fatal left cardiac failure caused by external compression of left internal mammary artery graft in an accident: a case report

We report for the first time a case of a 54 years old man with a fatal motorcycle accident due to an external bleeding compression of left internal mammary artery graft to the left anterior descending artery. The possibility of cardiac failure in trauma caused by external compression or traumatic injury of the graft should be considered in people who previously underwent coronary artery bypass graft surgery.

A Case Report of Coronary Subclavian Steal Syndrome in a Young Woman

A 41-year-old woman presented with complaints of increasing angina pectoris and coldness of her left arm for 1 month. Six months ago, she had undergone triple coronary artery bypass grafting (CABG) including left internal mammary artery (LIMA) to left anterior descending artery (LAD) and two saphenous vein grafts to the diagonal branch of LAD and obtuse marginal branch of the circumflex artery. Coronary angiography revealed that contrast media injected into the saphenous vein graft coursing down the diagonal branch flowed up to LAD and drained into the LIMA opacifying the left subclavian artery. Arch angiography documented a total occlusion of the left subclavian artery. A polytetrafluoroethylene graft was anastomosed between the left common carotid and axillary artery. After operation, the symptoms disappeared and blood pressure in her left arm recovered. This complication could be prevented by identification of subclavian artery stenosis during coronary angiogram or CABG. This study may suggest that subclavian artery angiography should be performed in patients who will undergo CABG even for a young woman such as our case.

Peripheral vascular disease endovascular management in patients scheduled for cardiac surgery: a clinical-angiographic approach

BACKGROUND

Endovascular management of peripheral vascular disease before cardiac surgery is still debated. We sought to present our preliminary experience of endovascular stent placement in patients scheduled for urgent cardiac surgery.

METHODS

Between November 2003 and August 2005, 20 patients scheduled for urgent coronary surgery (13 males, mean age 72.5+/-5.3 years) underwent endovascular repair of PVD on the basis of clinical and angiographic indications. Aspirin (100 mg/day) plus low molecular weight heparin (nadroparin calcium) 100 IU/kg/12 h for urgent coronary surgical revascularization was administered after the procedure.

RESULTS

Endovascular stenting has been performed in four clinical settings: renal artery stenting prior to coronary surgery (nine patients) to decrease the impact of extracorporeal circulation on an impaired renal function, iliac artery artery angioplasty and stenting (eight patients) in order to facilitate aortic balloon pump insertion after surgery, subclavian artery angioplasty and stenting propedeutical to arterial conduits bypass surgery (one patient), carotid artery stenting before coronary surgery (two patients). All patients underwent successful endovascular repair followed by cardiac surgery. At a mean follow-up of 12+/-4.6 months all patients are alive and without evident thrombosis or restenosis of the implanted vascular stents.

CONCLUSIONS

Endovascular treatment of PVD in patients scheduled for urgent coronary surgery may be effective, relatively safe and lasting in spite of low dose antiplatelet regimen.

Malpractice in Invasive Cardiology: Is Angiography of Abdominal Aorta or Subclavian Artery Appropriate in Patients Undergoing Coronary Angiography?

BACKGROUND

Identification of peripheral vascular disease by angiography in patients undergoing coronary angiography may be considered as malpractice but sometimes seems to be justified under clear entry criteria. The present mata-analysis is aimed to analyze the appropriateness and results of screening angiography of subclavian or abdominal aorta performed at the time of coronary angiography.

METHODS

A search of published literature for peripheral angiography in patients undergoing coronary angiography over the last 10 years was performed using the MEDLINE database. No language restriction was employed. Only studies enrolling more than 100 patients for abdominal aortography and 50 patients for subclavian/internal mammary artery angiography were considered. Reference lists from identified studies were also reviewed to identify other potentially relevant references.

RESULTS

Twenty-nine studies were retrieved: 8 articles about subclavian artery (SA) and internal mammary (IMA) angiography and 21 about renal (RA) and aortoiliac (AOI) angiography. The total number of patients enrolled was 27,936. Nine studies out of 29 were prospective. Defined entry criteria were reported in 24 out of 29 studies. Significant SA and IMA stenosis were reported in 5.5 and 9% of patients, respectively. RA stenosis >50% was present in 12.7% of patients with CAD. Finally, undetected AOI disease was reported in 35.5% of patients undergoing coronary angiography. Mean complication rate was 0.8 +/- 0.6%. Predictors of SA and IMA stenosis were unclear. Age, multi-risk profile, multi-vessel CAD, history of PVD or carotid disease, severe hypertension, unexplained renal dysfunction or decreased creatinine clearance have been reported most frequently as predictors of RA and AOI disease in patients undergoing coronary angiography.

CONCLUSIONS

Consistent evidence of appropriateness of renal angiography in selected patients undergoing coronary angiography have been produced in literature. IMA and AOI angiography seem to be not justified unless they are part of SA in patients scheduled for arterial conduit with brachial differential pressure, thoracic irradiation or surgery, or of abdominal angiography to detect RA stenosis in laboratories with radiological digital peripheral equipment.

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.