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

A case of carotid-axillary bypass for subclavian steal syndrome in an 83-year-old female undergoing hemodialysis

INTRODUCTION

Patients undergoing hemodialysis exhibit a high incidence of subclavian steal syndrome. Many cases of endovascular treatment for subclavian artery stenosis were only reported recently; however, the long-term results of surgical treatment are also important. Herein, we report a case of subclavian steal syndrome treated with common carotid-axillary bypass surgery in a patient undergoing hemodialysis.

PRESENTATION OF CASE

An 83-year-old woman experienced dizziness and pain in her left hand during hemodialysis. Computed tomography and angiography revealed severe stenosis and calcified lesions in the left subclavian artery. Ultrasonography revealed a retrograde blood flow waveform in the left vertebral artery. The patient was diagnosed with subclavian steal syndrome. We performed common carotid-axillary bypass for lesions that were difficult to revascularize via endovascular therapy. The post-operative course was uneventful, and the dizziness and numbness in the patient's left hand during dialysis disappeared. Post-operative ultrasonography revealed an antegrade blood flow waveform in the left vertebral artery.

DISCUSSION

Subclavian steal syndrome is an indication for revascularization in symptomatic patients. Endovascular treatment should be considered the first choice; however, surgery should be considered for patients in whom endovascular treatment is difficult, such as those with severe calcification. We chose common carotid-axillary artery bypass because the subclavian approach is a more familiar technique. Until 1 year post-operatively, the patient had not experienced any symptom recurrence, and the shunt flow was well maintained.

CONCLUSION

Common carotid-axillary bypass can be useful for revascularization of lesions for which endovascular therapy is considered difficult in patients with subclavian steal syndrome.

Atypical and rare cause of myocardial infarction: coronary subclavian steal syndrome (CSSS) treated by a carotid-subclavian bypass in a 71-year-old female patient

Background

The coronary subclavian steal syndrome (CSSS) is a rare complication after coronary arterial bypass graft operations (CABG) using the left or right internal mammary artery ((L/R)IMA). It results from a retrograde blood flow from the IMA into the subclavian artery (SA) due to a stenosis or occlusion of the SA proximal to the IMA origin. This “steal phenomenon” leads to a decreased blood flow in the IMA and may result in myocardial ischemia (MIS) and even myocardial infarction (MIN). Treatment options include interventional and surgical therapy.

Case presentation

We report the case of a 71-year old woman, who suffered from an acute non-ST elevation myocardial infarction (NSTEMI) 11 years after LIMA-CABG surgery and who was treated successfully with a carotid-subclavian bypass (CSB) after failed interventional therapy.

Conclusion

CSB may be regarded as a viable treatment option for patients suffering CSSS in the case of MIS and even an acute MIN/NSTEMI, especially in the case of missing or failed interventional therapy attempts. Specialists in cardiothoracic and vascular surgery should be aware of possible CSSS conditions and know about appropriate diagnostic and therapeutic options.

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.

Carotid axillary artery bypass: an option following failed open and percutaneous procedures

Percutaneous transluminal angioplasty and stenting is being employed with increasing frequency for stenosis involving the brachiocephalic circulation. However, the efficacy of these procedures is limited by intimal hyperplasia and subsequent re-stenosis. Long-term results for treating lesions of the subclavian or innominate artery have shown significant re-stenotic rate. Accordingly, carotid-subclavian bypass remains as an important procedure. Alternative methods may still be required, particularly after failure of open re-vascularization and percutaneous techniques. This report describes an underused technique that enables upper extremity revascularization following prior attempts at endovascular and standard open techniques.

Síndrome do roubo coronário-subclávio: relato de caso e revisão da literatura

O fenômeno do roubo coronário-subclávio é definido como o fluxo sanguíneo invertido de uma artéria coronária, por meio de enxerto de artéria mamária interna em direção à subclávia médio-distal, e ocorre devido à estenose significativa ou oclusão total da porção proximal desta última. É uma causa rara, mas significante, de isquemia cardíaca após cirurgia de revascularização miocárdica e pode originar uma síndrome de mesmo nome e com manifestações típicas. Relatou-se o caso de um paciente com esta enfermidade, que foi submetido à angioplastia percutânea com implante de stent. Também revisou-se a literatura a respeito.