Severe coronary artery spasm and subsequent coronary subclavian steal syndrome

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.

A forgotten vascular disease with important clinical implications. Subclavian steal syndrome

BACKGROUND

Subclavian Steal Syndrome (SSS) is a fascinating vascular phenomenon in which a steno-occlusive lesion of the proximal subclavian artery causes retrograde flow in the vertebral artery away from the brain stem subsequently causing vertebrobasilar insufficiency. SSS can present with a myriad of neurological and vascular signs and symptoms, but most commonly this phenomenon presents as an incidental finding in an asymptomatic patient.

CASE REPORT

Our patient is a 73-year-old female sent to the cardiology clinic for surgical clearance in preparation for an elective cholecystectomy. Shortness of breath was her only complaint. Review of systems was remarkable for left arm pain and blurry vision with repetitive movement. Physical examination noticeable for absence of left radial pulse. Percutaneous angiography demonstrated a totally occulted left subclavian artery with collateral circulation form the vertebrobasilar apparatus.

CONCLUSIONS

Atypical presentation of this unique entity represents a challenge for physicians who require a high index of suspicion to make the diagnosis. We present an atypical case with radiographical evidence of the steal syndrome, followed by an extensive literature review of the most current diagnostic methods as well as latest recommendations for treatment options and secondary prevention.