Interactive Cardiovascular and Thoracic Surgery 2:534-536(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Symptomatic coronary-subclavian steal syndrome due to total occlusion of proximal left subclavian artery
M. Adnan Celkana,*,
Bahadir Daglara,
Hakki Kazaza and
Hakan Dinckalb
a Department of Cardiovascular Surgery, Gaziantep University, School of Medicine, Gaziantep, Turkey
b Department of Cardiology, Gaziantep University, School of Medicine, Gaziantep, Turkey
* Corresponding author. Atatürk Bulvari Asaf Erkiliç, Apt. No: 94/7, 27090 Gaziantep, Turkey. Tel.: +90-342-336-1217; fax: +90-342-336-5505
celkan{at}superonline.com
Received April 19, 2003;
received in revised form June 15, 2003;
accepted June 18, 2003
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Abstract
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Symptomatic coronary-subclavian steal occurs infrequently. We report a case involving angina pectoris in a patient with a patent left internal thoracic artery graft on the left anterior descending coronary artery and total occlusion of the proximal left subclavian artery.
Key Words: Subclavian steal; Internal thoracic artery; Subclavian artery
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1. Introduction
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Recurrent angina after internal thoracic artery (ITA) coronary bypass surgery caused by significant proximal subclavian artery stenosis is an unusual complication of bypass surgery. The stenosis or occlusion of the subclavian artery proximal to the origin of the internal thoracic artery may result in reversal of ITA flow and produce myocardial ischemia. We present the case of a patient with both symptomatic occlusive disease of the subclavian artery and coronary artery disease in whom coronary-subclavian steal developed.
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2. Case report
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A 75-year-old man was admitted with intermittent chest pain and left arm cramping. The patient reported that chest pain radiating to the left shoulder and arm could easily be provoked by mild exercise. He had a history of coronary artery bypass grafting (CABG) 5 years previously with the left internal thoracic artery (LITA) to the left anterior descending artery (LAD) and saphenous vein grafts for the obtuse marginal and right coronary artery. Coronary angiography before previous CABG did not consist of LITA and subclavian artery angiography; however, physical examination of the patient included palpable bilateral radial and brachial arteries and he had no complaints of upper limb ischemia.
Physical examination on admission revealed no pulse on left brachial and radial arteries, and left arm arterial pressure could not be recorded. Bilateral carotid pulses could be palpated. An electrocardiogram showed myocardial ischemia in leads V1–3, D1 and trifascicular block. Laboratory tests showed normal cardiac enzymes and normal blood cell count. Echocardiography showed anterolateral and apical hypokinesia.
The patient was evaluated by full invasive coronary and brachiocephalic angiographic examination. The proximal stenosis and multiple plaques were present on the LAD, in first diagonal branch, in circumflex artery and in its first obtuse marginal branch, and in the right coronary artery. The previous vein bypass graft to the right coronary artery was patent, but the graft to the obtuse marginal branch was occluded proximally. Visualization of the LITA was not possible because of the proximal occlusion of the subclavian artery. Patency of the LITA was able to be demonstrated by retrograde opacification of the vessel during selective catheterization of the LAD (Fig. 1). The distal subclavian artery was visualized by retrograde opacification of the LAD. Aortography demonstrated total occlusion of the left subclavian artery at the proximal. Bilateral carotid arteries were patent.
During the operation, left subclavian artery exposure was obtained through a supraclavicular incision. The left common carotid artery was prepared anterior to the sternocleidomastoid muscle and isolated in the usual fashion. Subclavian endarterectomy was performed, and an 8-mm Dacron graft from the carotid to the subclavian artery was inserted under systemic heparinization. The postoperative course was uneventful and the patient had complete relief from the presenting symptoms.
Three months after the operation, the patient was called back for control angiographic examination. Carotico-subclavian bypass was patent and antegrade opacification of the LITA was seen (Fig. 2). During selective visualization of the LAD, retrograde opacification of the LITA could not be demonstrated. In addition, distal LAD was visualized on systole by the LITA.
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Fig. 2 Patent carotico-subclavian Dacron graft bypass (upright arrow), and antegrade opacification of the LITA (left arrow).
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3. Discussion
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The LITA is the preferred coronary artery bypass graft and conduit because of its excellent long-term patency and its relative resistance to atherosclerosis. However, flow in this vessel can be compromised by the disease of the subclavian artery proximal to the origin of the LITA. The stenosis results in retrograde flow in the ITA and steal from the coronary artery, causing ischemia to the area supplied by the graft [1,2]. Takach et al. reported that the incidence of coronary subclavian steal at their institution was less than 0.07% [3].
Coronary-subclavian steal syndrome is always suspected in patients with recurrent angina after CABG with an ITA, when a pressure gradient between the right and left arms is demonstrated [1,2]. All patients undergoing CABG should have bilateral preoperative blood pressure measurement. If the systolic blood pressure between the two arms differs by more than 20 mmHg, such patients should undergo angiography of the subclavian artery preoperatively [1].
The optimal management of patients with concomitant subclavian and coronary artery disease or coronary-subclavian steal has not been established. Transthoracic approach involving thoracotomy and then either subclavian endarterectomy and aorto-subclavian bypass has been reported to present excellent operative and long-term patency [4,5]. The most common extrathoracic operation is the carotid-subclavian bypass graft using a synthetic conduit, which has also been reported as having acceptable long-term patency [6]. More recently, angioplasty and stenting have been used to treat subclavian stenosis or short occlusions. These procedures have a low mortality and morbidity, with good short-term results [7]. However, long-term results are unknown. The choice of operative or interventional technique is determined by the individual risk factors and the anatomic distribution of the disease. In our patient, we preferred carotico-subclavian bypass with a synthetic Dacron graft, because this technique is more suitable for an elderly patient.
The cardiovascular surgeon must be aware of the potential risk of subclavian disease before coronary revascularization by using the ITA. The carotico-subclavian bypass procedure using an 8-mm Dacron graft may be the method of choice, because it has a lower potential for complication and is less technically demanding.
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Appendix A
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ICVTS on-line discussion
Author: Dr. Sameh Sersar, Assistant lecturer, Cardiothoracic surgery, Mansoura University, Mansoura 123, Egypt
Date: 11-Sep-2003
Message: What an interesting matter you went through. I wonder how many causes of steal Syndrome like adenosine and Amiodarone treatment, post CABG, anomalous origin of the left coronary artery from the pulmonary artery and non ligation of the vertebral artery during coarctation treatment by a subclavian flap angioplasty. Are there any differences between each steal of different causes?
doi:10.1016/S1569-9293(03)00134-8
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References
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Abstract
1. Introduction