Simultaneous subclavian artery reconstruction in coronary artery bypass grafting

Results of a hybrid procedure for patients with proximal left subclavian artery stenosis and coronary artery disease

OBJECTIVE

To assess whether a hybrid approach to the treatment of coronary artery disease with proximal left subclavian artery stenosis is superior to a staged approach.

METHODS

We retrospectively analyzed 20 patients who underwent percutaneous transluminal angioplasty (PTA) and stenting treatment combined with coronary artery bypass grafting on the same day (hybrid group) between January 2013 and October 2015, and compared them with 23 patients who underwent PTA and stenting followed by coronary artery bypass graft 4 weeks later (staged group) between January 2008 and December 2012. Demographic data, preoperative risk factors, intraoperative measures, and postoperative outcomes were analyzed.

RESULTS

The demographic data and preoperative risk factors were similar in the 2 groups. The total hospital length of stay was similar in the 2 groups, with a median of 9 days (range, 6-12 days) in the hybrid group versus 9 days (range, 8-15 days) in the staged group (P = .299). There were no postoperative complications (eg, myocardial infarction, stroke, renal failure) in either group. In both groups, the mortality rate was 0 in the hospital, at 1 month, and at 3 months. All patients in both groups had no symptom recurrence at follow-up. Angiography showed no significant difference in postoperative stenosis between the 2 groups at 3 months (P = .762).

CONCLUSIONS

The hybrid procedure of PTA and stenting followed by coronary artery bypass grafting may be an effective approach for patients with concomitant proximal left subclavian artery stenosis and coronary artery disease.

Bilateral subclavian steal syndrome

Bilateral subclavian steal syndrome is a rare condition. It is usually due to reversal of vertebral blood flow in the setting of bilateral proximal subclavian or left subclavian plus innominate artery severe stenosis or occlusion. This finding may cause cerebral ischemia related to upper extremities exercise. We report a case of bilateral subclavian steal secondary to total occlusion of the innominate and left subclavian arteries in a patient who presented with cardiomyopathy and flow reversal in the right carotid and bilateral vertebral arteries.

The coronary-subclavian-vertebral steal syndrome (CSVSS)

OBJECTIVE

Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or-in addition with cerebral symptoms-in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS).

METHOD

We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks.

RESULTS

A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case. Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery.

CONCLUSION

The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.

Concomitant aortoaxillary bypass and coronary artery bypass grafting

The optimal revascularization strategy for patients with subclavian and coronary artery disease has not been established. This study assessed the mid-term clinical outcome of concomitant aortoaxillary bypass and coronary artery bypass grafting in 5 patients. A ring-reinforced polytetrafluoroethylene graft was attached to the ascending aorta and led to the proximal segment of the axillary artery via the pleural cavity. Patients were followed up for 2-10 years (mean, 5.4 +/- 3.4 years). Postoperative aortography and angiography demonstrated patent aortoaxillary and coronary bypass grafts in the short-term follow-up of all patients. Two patients with Takayasu aortitis needed re-operations for recurrent angina and annuloaortic dilatation. Another patient required removal of the aortoaxillary bypass graft because of infection, and subsequently underwent a left femoroaxillary bypass one year after the original procedure. Subclavian steal phenomenon did not occur. Aortoaxillary bypass with coronary artery bypass may be an effective option for patients with co-existing subclavian and coronary artery disease.

Endovascular repair of symptomatic coronary-subclavian steal syndrome due to stenosis of the proximal left subclavian artery

We report a patient with left subclavian artery stenosis in whom the internal thoracic artery (ITA) had been used as a coronary bypass. She presented with symptomatic myocardial and brain ischemia resulting from coronary-subclavian steal syndrome and was successfully treated with angioplasty and stenting.

Coronary subclavian steal syndrome: non-invasive imaging and percutaneous repair

Although coronary subclavian steal syndrome (CSSS) is relatively uncommon, it is a well documented cause of graft failure in patients having undergone coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA). Here we report a case of CSSS induced by restenosis of a left subclavian artery (SCA) origin stent, identified by increased velocities within the stent and an abnormal ipsilateral vertebral artery (VA) waveform on Duplex ultrasound imaging. This was successfully treated percutaneously by re-stenting, resulting in restoration of normal SCA waveforms and velocities, and normalization of the ipsilateral VA waveform.

Endovascular therapy in prevention and management of coronary-subclavian steal

BACKGROUND

The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal.

METHODS

The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed.

RESULTS

Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%.

CONCLUSION

PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.

Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up

The authors report their experience with percutaneous transluminal angioplasty (PTA) and stenting of the left subclavian artery (LSA) in patients with recurrent angina and a left internal mammary (LIMA)-coronary bypass graft or in patients who will be undergoing LIMA-coronary artery bypass grafting. From November 1990 to February 2001, 21 patients (11 men and 10 women) with significant left subclavian artery stenosis were treated; 18 patients had a prior LIMA bypass graft, and 3 patients were treated before coronary artery bypass surgery. Angiographic follow-up was performed in 12 patients and clinical follow-up was obtained in all patients. All lesions were atherosclerotic in etiology and located in the proximal left subclavian artery. The mean stenosis was 81% (range 50-100%). All patients initially underwent PTA. Stents were placed in 7 patients for suboptimal PTA results. Technical success was achieved in all patients. Pressure gradient measurements were available in 6 patients. Mean pretreatment gradient was 29 mm Hg (range, 10-50 mm Hg) and fell to 3 mm Hg (0-8 mm Hg) posttreatment. There were 2 minor and 2 major complications. The 30-day mortality rate was 9.5% (2 patients). The remaining 19 patients had clinical or angiographic follow-up of 4-68 months (mean, 27 months). Three patients were found to have recurrent stenoses by angiography 8-43 months after PTA and 3 more had clinical signs of recurrent stenosis. Therefore, the long-term clinical patency rate of LSA PTA and stent was 15 of 19 (79%). One was managed with bypass surgery, 1 with repeat PTA and stent placement, and 1 was managed conservatively. Therefore, the assisted patency was 15 of 19 (79%). Eleven of 19 (58%) of the patients in long-term follow-up had cardiac symptoms, but repeat angiography excluded recurrent LSA stenosis as the cause of their symptoms in 7 cases. Only 4/19 (21%) had cardiac symptoms potentially attributable to LSA restenosis. Four patients expired during follow-up, but 3 had no evidence of subclavian stenosis. PTA and stenting is an effective treatment of proximal left subclavian artery stenosis in patients who develop angina after a LIMA-coronary artery bypass, or in patients before a LIMA-CABG. Cardiac symptoms after LSA PTA and stent are most often due to progressive coronary artery disease rather than to recurrent LSA stenosis.

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 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.