Stenting for Left Subclavian Artery Stenosis before and after Coronary Artery Bypass Grafting Using the Internal Mammary Artery: A Report of Three Cases

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

A Comparison of Nephrotoxicity of Contrast Medium in Elderly Patients who Underwent Renal or Peripheral Arterial Vascular Intervention

OBJECTIVE

To compare the nephrotoxicity of iodixanol in elderly patients who underwent a renal artery intervention (RAI) with those who underwent an other peripheral vascular intervention (OPI).

METHODS

Three hundred fifty-four consecutive patients (>60 years old) received iodixanol during RAI (n=150) or OPI (n=204). The level of serum creatinine (SCr) was measured at the baseline, 24 hours, 48 hours, 72 hours and 1 month after intervention.

RESULTS

Within 72 hours after the intervention, the adjusted mean of the peak SCr increase was 11.22 umol/L 〔95% confidence interval (CI): 9.21-13.24〕 in the RAI group and 12.40 umol/L (95%CI: 10.7-14.09) in the OPI group. The difference in the peak SCr increase was -1.17 umol/L (95%CI: -3.94-1.60; p=0.406). Contrast-induced nephropathy occurred in 26 patients (17.3%) of the RAI group and in 27 patients (13.2%) of the OPI group (p=0.286). Patients who underwent an RAI showed no increased risk for contrast-induced nephropathy in comparison with patients who underwent an OPI 〔adjusted odds ratio (OR)=1.108; 95%CI: 0.540-2.273; p=0.780〕.

CONCLUSION

The nephrotoxic effect of iodixanol in elderly patients who underwent RAI or OPI was comparable.

Left subclavian artery stenting: an option for the treatment of the coronary-subclavian steal syndrome

Introduction

The subclavian steal syndrome is characterized by the vertebral artery flow inversion, due to a stenotic lesion in the origin of the subclavian artery. The Coronary-subclavian Steal Syndrome is a variation of the Subclavian Steal Syndrome and is characterized by inversion of flow in the Internal Thracic artery that has been used as conduct in a myocardial revascularization. Its diagnosis must be suspected in patients with difference in pulse and arterial pressure in the upper limbs, that present with angina pectoris and that have done a myocardial revascularization. Its treatment must be a surgical bypass or a transluminal angioplasty.

Objective

The objective is to show the left subclavian artery stenting as a safe and effective method to treat the coronary-subclavian steal syndrome.

Methods

Historical prospective, non-randomized trial, through revision of the hospital records of the patients treated with the stenting of the left subclavian artery, from January 2006 to September 2012.

Results

In the mentioned period, 4.291 miocardial revascularizations were performed with the use of the left mammary artery, and 16 patients were identified to have the Coronary-subclavian steal syndrome. All of them were submitted to endovascular treatment. The success rate was 100%; two patients experienced minor complications; none of them presented with major complications. Eleven of the 16 patients had ultrassonographic documentation of patent stent for at least one year; two patients lost follow up and other two died.

Conclusion

The stenting of the left subclavian artery is a good option for the treatment of the Coronary-subclavian Steal Syndrome, with high level of technical and clinical success.

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.

High-risk acute coronary syndrome in a patient with coronary subclavian steal syndrome secondary to critical subclavian artery stenosis

Patients with multivessel coronary artery disease are more likely to have extensive atherosclerosis that involves other major arteries. Critical subclavian artery (SCA) stenosis can result in coronary subclavian steal syndrome that may present as recurrent ischemia and even myocardial infarction in patients with coronary artery bypass graft (CABG). In patients with concomitant severe native coronary disease, occluded saphenous venous grafts (SVG) to other arteries, percutaneous intervention on critical subclavian artery (SCA) stenosis that will compromise the blood flow to left internal mammary graft (LIMA) and left anterior descending (LAD) artery will be a high-risk procedure and may be associated with cardiogenic shock, especially in patients with preexisting ischemic cardiomyopathy. The use of percutaneous left ventricular (LV) assist device like Impella will offer better hemodynamic support and coronary perfusion and therefore results in decreased myocardial damage, maximized residual cardiac function, and lower incidence of cardiogenic shock.