Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery

Frequency of subclavian artery stenosis in patients with mammarian artery coronary bypass and suspected coronary artery disease progression

We retrospectively analyzed patient records of all patients with a history of internal mammarian artery (IMA) coronary bypass undergoing coronary angiography at two cardiovascular centers between January 1st 1999 and December 31st 2019. A total of 11,929 coronary angiographies with or without percutaneous coronary intervention were carried out in 3921 patients. Our analysis revealed 82 (2%) patients with documented subclavian artery stenosis. Of these, 8 (10%) patients were classified as having mild, 18 (22%) moderate, and 56 (68%) severe subclavian artery stenosis. In 7 (9%) patients with subclavian artery stenosis, angiography revealed occlusion of the IMA graft. 26 (32%) patients with severe subclavian artery stenosis underwent endovascular or surgical revasculararization of the subclavian artery. In this retrospective multicenter study, subclavian artery stenosis was a relevant finding in patients with an internal mammarian artery coronary bypass graft undergoing coronary angiography. The development of dedicated algorithms for screening and ischemia evaluation in affected individuals may improve treatment of this potentially underdiagnosed and undertreated condition.

Coronary-subclavian steal syndrome: a case report of a rare entity that can become a deadly threat

Background

In patients who underwent coronary artery bypass graft (CABG), the coronary-subclavian steal syndrome (CSSS) is characterized by a subclavian artery stenosis proximal to the origin of the internal mammary artery resulting in functional graft failure.

Case summary

A 62-year-old gentleman underwent CABG following a non-ST elevation myocardial infarction and an angiogram showing left main stem and three-vessel disease. Forty-eight hours later he developed cardiogenic shock that improved with inotropic support and intra-aortic balloon pump insertion. However, 7 days later, he deteriorated again and even though the myocardial injury markers and echocardiogram were normal, an angiography was performed showing significant CSSS. Due to the chronic nature of his subclavian stenosis and the severity of the cardiogenic shock, the heart team decided to treated his epicardial disease percutaneously and occlude the left internal mammary artery in its mid-segment with coils. The patient was discharged home 28 days after CABG and has remained since asymptomatic with improvement in his functional class.

Discussion

Coronary-subclavian steal syndrome is a rare but fatal complication with increased morbidity and mortality due to reduced awareness amongst medical professionals. Subclavian artery stenosis stenting is the gold standard treatment; herein we present a new approach for complex and very sick patients in whom it is not possible to open the subclavian artery percutaneously. Increased awareness and prompt diagnosis of this pathology in CABG patients are essential for successful outcomes.

[Treatment of atherosclerotic lesion of the first segment of subclavian artery]

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

Background

Coronary subclavian steal syndrome (CSSS) is an uncommon complication observed in patients after coronary artery bypass surgery with left internal mammary artery (LIMA) grafts. It is defined as coronary ischaemia due to reversal flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. In practice, the entire clinical spectrum of ischaemic heart disease, ranging from asymptomatic patients to acute myocardial infarction, may be encountered.

Case summary

Three cases of CSSS recently detected at our hospital are being described. Two patients presented with an acute coronary syndrome, so diagnosis was suspected based on coronary angiography findings, as retrograde blood flow from LIMA to the distal SA was present. Myocardial ischaemia was documented by myocardial perfusion scintigraphy in one case. The third patient was asymptomatic and CSSS was suspected during physical examination and confirmed by computed tomography (CT). Endovascular intervention with balloon-expandable stent implantation of the stenotic SA was performed by vascular surgeons in all patients. No periprocedural complications occurred, and complete resolution of symptoms was achieved.

Discussion

In CSSS, subclavian angiography is the standard diagnostic test. However, other diagnostic techniques may be valuable to better clarify this challenging diagnosis. In the herein small series, the usefulness of a multimodality imaging approach including Doppler ultrasound, myocardial perfusion scintigraphy, and CT is well demonstrated. Furthermore, this study endorses the safety and utility of endovascular treatment in different clinical scenarios, including asymptomatic patients.

An Interesting Case of a Cold Left Arm

Inter-arm variability in blood pressure readings typically signifies arterial disease between the aortic arch and the subclavian artery. The differential diagnosis includes thoracic aortic dissection, atherosclerosis, thoracic outlet syndrome, and subclavian artery stenosis and thrombosis. In patients with prior coronary artery bypass grafting, including the internal mammary artery, several of those conditions can compromise coronary blood flow and lead to myocardial ischemia. Here we discuss a case of left subclavian artery thrombosis, which compromised left internal mammary artery blood flow and led to ischemic ventricular tachycardia.

Carotid, Vertebral, and Brachiocephalic Interventions

Carotid atherosclerosis most frequently manifests in the proximal internal carotid artery and the common carotid artery bifurcations. Subclavian artery atherosclerosis affects the proximal segments with a relatively higher incidence on the left and becomes clinically important in the presence of vertebrobasilar insufficiency or coronary steal. Atherosclerosis of the vertebral artery can lead to posterior circulation stroke. The authors review the major trials on carotid carotid, brachiocephalic and vertebral artery stenosis along with the various available diagnostic and interventional techniques.

A Case of Subclavian Artery Thrombosis

Subclavian artery thrombosis is a rare cause of upper limb ischemia resulting from occlusion of the upper extremity blood supply. Symptomatic presentation is quite rare and therefore remains underdiagnosed by physicians. Possible catastrophic clinical consequences necessitate prompt rectification of the underlying disease and risk factors. Treatment modalities are often selected depending on the severity of clinical presentation. Herein, we present a case of a 52-year-old man who presented to the outpatient department with a one-month history of pain and blackish discoloration of the right-hand digits, palm, and wrist. His social history also revealed a chronic 30-year history of smoking. At the time of consultation, his past medical history was insignificant for chronic medical disease and hospitalizations. However, inpatient investigations diagnosed him with diabetes. Physical examination revealed a bad odor emanating from the devitalized affected right hand. Neurological examination was significant for the loss of pain sensation in the right hand. Furthermore, the right radial and brachial pulses were also absent (grade 0). Right upper extremity angiography revealed the occlusion of the right subclavian artery and right brachial artery. Above elbow amputation was advised and performed based on angiogram scans and physical examination findings. We report a case of subclavian artery thrombosis in an undiagnosed diabetic with a chronic history of smoking. Our report details the common etiology, clinical presentation, and management options feasible for this clinical entity. Furthermore, it reiterates the importance of counseling patients to attend annual healthcare doctor visits.

An unusual cause of ischemia after coronary bypass grafting!!

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome.

Review of coronary subclavian steal syndrome

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.

Subclavian Artery Disease: Diagnosis and Therapy

The diagnosis of brachiocephalic disease is often overlooked. Symptoms include arm claudication and vertebrobasilar insufficiency. In patients who have had the use of the internal mammary artery for coronary bypass surgery, the development of symptoms of myocardial ischemia should alert the clinician to the possibility of subclavian artery stenosis. Also, in patients who have had axillofemoral bypass, lower-extremity claudication may occur. Recognition involves physical examination and accurate noninvasive testing. Endovascular therapy has proven to be effective in alleviating symptoms in properly selected patients.

Subclavian Steal Syndrome in Acute Myocardial Infarction Masquerading as Acute Embolism to Left Upper Extremity

Subclavian steal syndrome is an uncommon entity diagnosed with angiography after neurologic symptoms occur during activity with the upper extremity. Cardiac symptoms or silent ischemia have been described in patients who have undergone cardiac bypass using the ipsilateral internal mammary artery. Our patient presented with acute chest pain radiating to the left upper extremity and a diminished pulse. Angiography to rule out an acute embolus instead revealed subclavian artery occlusion. As atherosclerosis is the most common cause, the ipsilateral subclavian artery should be carefully evaluated, particularly in cardiac patients undergoing coronary angiography. Recognition of coexisting subclavian artery occlusion could prevent cardiac complications that may occur with use of the ipsilateral internal mammary artery during coronary artery bypass surgery.

Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis

Association of inter-arm systolic blood pressure difference (IASBPD) with cardiovascular (CV) morbidity and mortality remains controversial. We aimed to thoroughly examine all available evidence on inter-limb blood pressure (BP) difference and its association with CV risk and outcomes. We searched PubMed, EMBASE, CINAHL, Cochrane library, and Ovid for studies reporting bilateral simultaneous BP measurements in arms or legs and risk of peripheral arterial disease (PAD), coronary artery disease, cerebrovascular disease, subclavian stenosis, or mortality. Random-effect meta-analysis was performed to compare effect estimates. Twenty-seven studies met inclusion criteria, but only 17 studies (18 cohorts) were suitable for analysis. IASBPD of 10 mmHg or more was associated with PAD (risk ratios, 2.22; 1.41-3.5; P = .0006; sensitivity 16.6%; 6.7-35.4; specificity 91.9%; 83.1-96.3; 8 cohorts; 4774 subjects), left ventricular mass index (standardized mean difference 0.21; 0.03-0.39; P = .02; 2 cohort; 1604 subjects), and brachial-ankle pulse wave velocity (PWV) (one cohort). Association of PAD remained significant at cutoff of 15 mmHg (risk ratios, 1.91; 1.28-2.84; P = .001; 5 cohorts; 1914 subjects). We could not find statistically significant direct association of coronary artery disease, cerebrovascular disease, CV, and all-cause mortality in subjects with IASBPD of 10 mmHg or more, 15 mmHg or more, and inter-leg systolic BP difference of 15 mmHg or more. Inter-leg BP difference of 15 mmHg or more was strong predictor of PAD (P = .0001) and brachial-ankle PWV (P = .0001). Two invasive studies showed association of IASBPD and subclavian stenosis (estimates could not be combined). In conclusion, inter-arm and leg BP differences are strong predictors of PAD. IASBPD may be associated with subclavian stenosis, high left ventricular mass effect, and higher brachial-ankle PWVs. Inter-leg BP difference may also be associated with high left ventricular mass effect and higher brachial-ankle PWVs. Presence of inter-limb BP difference may indicate higher global CV risk.

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.

Coronary Subclavian Steal Syndrome Evaluated with Multimodality Imaging

In patients with mammary-coronary bypass grafts, the presence of a subclavian artery stenosis proximal to the internal mammary artery may result in a condition termed coronary-subclavian steal syndrome of which the incidence varies between 0.07-3.4% among those requiring coronary grafts. We reported a patient with a history of the coronary artery bypass graft who presented with typical angina pectoris at rest that was exacerbated by selective exercise of the left upper extremity in whom occlusion of the left subclavian artery was demonstrated in this patient by 3D reconstruction of computed tomography angiography, a reversal blood flow in the left internal mammary artery-left anterior descending artery graft by Doppler ultrasonography, and a coronary angiography.

Effective emergent endovascular recanalization for acute coronary syndrome with left subclavian artery occlusion in a prior coronary artery bypass graft patient

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.

Aortic arch vessel disease and rationale for echocardiographic screening

Atherosclerosis of the proximal branches of the aortic arch has compelling clinical implications that warrant the application of direct noninvasive detection of the disease. The prevalence of aortic arch vessel disease in an aging and at-risk community and clinical population has been underreported and undertreated despite an associated increase of all-cause and cardiovascular mortality. Intrathoracic duplex imaging has been validated as an accurate noninvasive tool to detect, characterize, and follow native aortic arch vessel disease and its sequelae and correction. Such duplex techniques are easily integrated into routine echocardiography with focused training and minimal time investment in the examination. A paucity of available resources exists across disciplines regarding ultrasonographic investigation of these supra-aortic trunk vessels, including textbooks, journal articles, seminars, and manuals. This review has been compiled to familiarize physicians and sonographers with the relevant anatomy, pathophysiology, treatment, and diagnostic duplex surveillance of aortic arch vessel disease. Illustrative cases along with clinical rationale are discussed with the intent to facilitate the integration of arch vessel duplex imaging into the scope and practice of echocardiography.

Successful percutaneous revascularization of totally occluded left subclavian artery using orbital atherectomy

Subclavian artery steal (SAS) after coronary artery bypass graft (CABG) has been reported to be as high as 3.4%. These patients with patent left internal mammary artery (LIMA) anastomosis will also have coronary-subclavian steal syndrome (CSSS). Percutaneous intervention (PCI) by balloon angioplasty (BA) and stenting has been done successfully for subclavian artery (SA) stenosis. The visibility of the vertebral artery (VA) and LIMA during BA and stent positioning is extremely important. Debulking total occlusions by orbital atherectomy (OA) and avoiding unnecessary BA, stenting across side branches may decrease the chance of plaque shifting and subsequent loss of flow especially if they have ostial disease. Herein we report successful OA, BA and stenting of chronic total occlusion (CTO) of proximal left subclavian artery in a patient with coronary-subclavian steal syndrome with preservation of LIMA and diseased left vertebral artery (VA).

Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis

BACKGROUND

Differences in systolic blood pressure (SBP) of 10 mm Hg or more or 15 mm Hg or more between arms have been associated with peripheral vascular disease and attributed to subclavian stenosis. We investigated whether an association exists between this difference and central or peripheral vascular disease, and mortality.

METHODS

We searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, and Medline In Process databases for studies published before July, 2011, showing differences in SBP between arms, with data for subclavian stenosis, peripheral vascular disease, cerebrovascular disease, cardiovascular disease, or survival. We used random effects meta-analysis to combine estimates of the association between differences in SBP between arms and each outcome.

FINDINGS

We identified 28 eligible studies for review, 20 of which were included in our meta-analyses. In five invasive studies using angiography, mean difference in SBP between arms was 36·9 mm Hg (95% CI 35·4-38·4) for proven subclavian stenosis (>50% occlusion), and a difference of 10 mm Hg or more was strongly associated with subclavian stenosis (risk ratio [RR] 8·8, 95% CI 3·6-21·2). In non-invasive studies, pooled findings showed that a difference of 15 mm Hg or more was associated with peripheral vascular disease (nine cohorts; RR 2·5, 95% CI 1·6-3·8; sensitivity 15%, 9-23; specificity 96%, 94-98); pre-existing cerebrovascular disease (five cohorts; RR 1·6, 1·1-2·4; sensitivity 8%, 2-26; specificity 93%, 86-97); and increased cardiovascular mortality (four cohorts; hazard ratio [HR] 1·7, 95% CI 1·1-2·5) and all-cause mortality (HR 1·6, 1·1-2·3). A difference of 10 mm Hg or higher was associated with peripheral vascular disease (five studies; RR 2·4, 1·5-3·9; sensitivity 32%, 23-41; specificity 91%, 86-94).

INTERPRETATION

A difference in SBP of 10 mm Hg or more, or of 15 mm Hg or more, between arms might help to identify patients who need further vascular assessment. A difference of 15 mm Hg or more could be a useful indicator of risk of vascular disease and death.

FUNDING

Royal College of General Practitioners, South West GP Trust, and Peninsula Collaboration for Leadership in Applied Health Research and Care.

Subclavian artery stenosis: a review for the vascular medicine practitioner

Peripheral artery disease assessment typically focuses on the evaluation of lower extremity symptoms and physical findings. Few practitioners consider the importance of upper extremity arterial disease; which, besides causing hand and arm symptoms, can be associated with significant neurologic and cardiac sequelae. A review of the existing literature through PubMed using the search term 'subclavian stenosis' was performed. The latest original articles, including clinical studies, case reports and limited reviews of this topic were adapted. A comprehensive article review focusing on the diagnostic and treatment approach for subclavian stenosis was prepared. In conclusion, vascular medicine practitioners including cardiologists and vascular surgeons caring for patients with arterial disease should routinely assess for subclavian stenosis. There are excellent screening tools and effective medical therapies which can be instituted if diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness.

Massive coronary subclavian steal syndrome

Coronary subclavian steal syndrome is an unusual cause of angina, secondary to decreased or reversed flow in patients with patent "in situ" internal mammary-to-coronary artery graft. The most frequent cause of coronary subclavian steal syndrome is ipsilateral subclavian artery stenosis. We present a 60-year-old man with cerebrovascular and peripheral artery disease and a documented massive coronary subclavian steal syndrome, which impaired cardiopulmonary bypass weaning after multiple coronary artery bypass with double T-mammary artery graft.

A case report of coronary-subclavian steal syndrome treated with carotid to axillary artery bypass

Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. This rare complication of cardiac revascularisation leads to recurrence of myocardial ischaemia. When feasible, subclavian angioplasty and/or stent placement can provide acceptable result for these patients. Vascular reconstruction through carotid to subclavian artery bypass has been the standard procedure of choice. Other interventions in literature include axilloaxillary bypass and subclavian carotid transposition. This case report describes the use of carotid axillary artery bypass for the treatment of coronary-subclavian steal syndrome.

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.

Diagnosis and Management of Subclavian Artery Stenosis Prior to Coronary Artery Bypass Grafting in the Current Era

There are several approaches to managing subclavian artery stenosis (SAS) prior to coronary artery bypass grafting (CABG) with an intended internal thoracic artery (ITA) graft to the left anterior descending (LAD) artery. We herein review the incidence of and various diagnostic modalities for detecting SAS. Published relevant clinical studies from the interventional cardiovascular and cardiac surgical literature are summarized. Particular emphasis is placed on the efficacy of various approaches to the patient diagnosed with SAS prior to CABG. Stenting the subclavian artery prior to bypass surgery and using an in situ ITA is compared to using the ITA as a "free" graft. The incidence of restenosis after subclavian artery angioplasty or stenting is not trivial and has been reported to occur at a rate of 6% to 21%; however, the average rate of restenosis with stenting appears to be in the mid-teens. Subacute subclavian stent thrombosis or occlusion is exceptionally rare, suggesting that a percutaneous approach to SAS is reasonable prior to CABG. For patients requiring emergent revascularization, placement of a free ITA graft to the LAD appears to be a safe and durable treatment as patency rates are comparable to that of an in situ LITA to the LAD. In summary, although no randomized clinical trials address the optimal management of SAS prior to CABG, both percutaneous and surgical options appear to be safe and reasonably durable.

Myocardial thievery: the coronary-subclavian steal syndrome

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.

Acute occlusion of the left subclavian artery causing a non-ST-elevation myocardial infarction with subacute lung edema due to a coronary subclavian steal syndrome—A case report

Subclavian artery occlusion causing an anterior non-ST-elevation myocardial infarction in a patient with a left internal mammary artery bypass to the left anterior descending artery. Presentation of a case not previously described in the literature to our knowledge.

Percutaneous Angioplasty and Stenting of left Subclavian Artery Lesions for the Treatment of Patients with Concomitant Vertebral and Coronary Subclavian Steal Syndrome

OBJECTIVE

To evaluate the efficacy of subclavian stenosis percutaneous transfemoral angioplasty (PTA)-treatment in patients with intermittent or complete subclavian steal syndrome (SSS), and coronary-subclavian steal syndrome (C-SSS) after left internal mammary artery-interventricular anterior artery (LIMA-IVA) by pass graft.

METHODS

We studied 42 patients with coronary subclavian steal syndrome subdivided in two groups; the first group consisted of 15 patients who presented an intermittent vertebral-subclavian steal, while the second group consisted of 27 patients with a complete vertebral-subclavian steal. All patients were treated with angioplasty and stent application and were followed up for a period of 5 years by echocolordoppler examination to evaluate any subclavian restenosis.

RESULTS

Subclavian restenosis was significantly increased in patients with a complete subclavian steal syndrome. The restenosis rate was 6.67% in the first group and 40.75% in the second group, These patients had 9.1 fold-increase risk (CI confidence interval 0.95-86.48) in restenosis.

CONCLUSION

Patients with a complete subclavian and coronary steal syndrome present a higher risk of subclavian restenosis.

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.

[Rare cause of pectangina after coronary artery surgery]

The coronary subclavian-steal-syndrome is a rare cause for angina pectoris following A. mammaria interna bypass operation. A 72-year-old male patient presented with vertigo and angina pectoris. A three vessel coronary artery disease was known and coronary artery surgery with three aortocoronary bypasses had been performed a year prior to presentation. A difference in peripheral arterial pressure between the right (150/80 mmHg) and the left (125/75 mmHg) arm was noted at physical examination. Color Doppler sonography of the left vertebral arteria exhibited a retrograde flow suggesting a coronary subclavian-steal-syndrome. Angiography revealed a significant stenosis of the left arteria subclavia. The stenosis was successfully treated with percutaneous transluminal angioplasty and stent implantation.

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.

Coronary Subclavian Steal Syndrome

Inappropriate alterations in flow in the form of steal syndromes are a well recognised phenomenon. In the subclavian steal syndrome a proximal subclavian artery stenosis is responsible for reversal of flow in the vertebral artery and symptoms of vertebrobasilar ischaemia occur with arm movement. After internal mammary artery grafting to the coronary circulation, during coronary artery bypass surgery (CABG), coronary subclavian steal can occur. Retrograde flow occurs from the myocardium through the internal mammary graft to the subclavian artery secondary to a proximal subclavian stenosis. It is a rare but important cause of recurrent chest pain after coronary surgery.

Restenting for subclavian in-stent restenosis with symptomatic recurrent coronary-subclavian steal

PURPOSE

To determine whether restenting for recurrent coronary-subclavian syndrome is technically feasible, provides durable results, and is a reasonable alternative to surgery.

CASE REPORT

A 58-year-old woman with a left internal mammary artery (LIMA) bypass to the left anterior descending artery underwent angioplasty and stent placement for left subclavian stenosis and coronary-subclavian steal. Twenty-three months later, she returned with progressive angina and left arm claudication; heart catheterization demonstrated restenosis of the subclavian artery at the stent site with recurrence of the coronary-subclavian steal. Successful redo angioplasty and stenting resulted in normal antegrade flow through the LIMA graft. The patient has remained asymptomatic for 3 years without evidence of recurrent in-stent stenosis on serial noninvasive studies.

CONCLUSIONS

Restenting is technically feasible and appears to be a durable response to subclavian in-stent restenosis in patients with coronary subclavian steal.