Coronary-subclavian steal syndrome causing myocardial infarction after arteriovenous fistula creation: a case report.

Coronary subclavian steal syndrome (CSSS) caused by left subclavian artery (LSA) stenosis is a rare cause of myocardial infarction in patients having coronary artery bypass grafting (CABG), and it has also been observed after an arteriovenous fistula (AVF) was made. A 79-year-old woman who had undergone CABG years earlier and an AVF creation 1 month before experienced a non-ST-elevation myocardial infarction (NSTEMI). While selective catheterization of the left internal thoracic artery graft was impossible, a computed tomography scanner showed patency of all bypasses and proximal subocclusive LSA stenosis, and the digital blood pressure measurements objectified a haemodialysis-induced distal ischaemia. LSA's angioplasty and covered stent placement were successfully performed, resulting in symptom remission. A CSSS-induced NSTEMI due to a LSA stenosis aggravated by a homolateral AVF several years after CABG has been documented only infrequently. If vascular access is required in the presence of CSSS risk factors, the contralateral upper limb should be preferred.

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.

Coronary Subclavian Steal Syndrome: A Contemporary Review.

Coronary subclavian steal syndrome (CSSS) is a rare cause of angina. It occurs in patients with prior coronary artery bypass grafting and, specifically, a left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. In this context, there is retrograde blood flow through the LIMA to LAD graft to supply the subclavian artery beyond the significant stenosis. This potentially occurs at the cost of compromising coronary artery perfusion dependent on the LIMA graft. In this review, we present a case of a middle-aged female who suffered from CSSS and review the literature for the contemporary diagnosis and management of this condition.

Coronary-subclavian steal syndrome, an easily overlooked entity in interventional cardiology.

Coronary-subclavian steal syndrome (CSSS) is a severe complication of coronary artery bypass graft (CABG) surgery with internal mammary artery grafting. It is caused by functional graft failure due to a hemodynamically significant proximal subclavian artery stenosis. In this manuscript, we provide a comprehensive review of literature and we report a series of five consecutive CSSS cases. This case series illustrates the variable clinical presentation, thereby emphasizing the importance of raised awareness concerning this pathology in CABG patients.

Distal Revascularization and Interval Ligation as a Useful Option for Steal Syndrome.

Distal revascularization and interval ligation (DRIL) is considered a useful option to relieve haemodialysis access-related steal syndrome. The results of this procedure are not known in the local setup. This is a case series of patients who underwent DRIL between January 2005 and December 2015. A total of ten patients (9 females) were included in the study. All the patients presented with grade 3 steal syndrome. Seven patients had rest pain while three had tissue loss. Polytetrafluoroethylene was used in all patients as the brachio-brachial bypass graft. All patients had smooth recovery except one patient who had postoperative brachio-brachial graft thrombosis and required thrombectomy. In all the cases, access was preserved. Steal symptoms resolved completely in all patients except for two, who had partial relief of rest pain and neurological symptoms. DRIL is a safe and effective procedure for resolution of steal syndrome and in preserving access at the same time.

Left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome: A review of literature on therapy, intervention, and management.

Coronary artery anomalies (CAA) are anatomical aberrations in the origin, structure, and course of the epicardial arteries. Literature has detailed common anomalies or fistulas formed because of coronary artery bypass grafting (CABG) manipulation of intrathoracic vessels. Despite the commonality of the CABG procedure, there are a few CAA and fistula findings which remain extremely rare. We present a case of left internal mammary artery to pulmonary artery fistula causing coronary steal syndrome that presented symptomatically as a malignant arrhythmia. Following a literature review of therapy, intervention, and management we recommend a team based approach when faced with this extremely rare case presentation. The goal of management should to reduce symptoms, and ischemia, by reducing or stopping flow through the fistula and out of the coronary blood supply.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery.

BACKGROUND: The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. METHODS: A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. RESULTS: The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months.Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. CONCLUSIONS: In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Subclavian artery stenting for coronary-subclavian steal syndrome.

OBJECTIVES: To evaluate the safety and feasibility of subclavian artery stenting for coronary-subclavian steal syndrome (CSSS). BACKGROUND: CSSS is a rare cause of myocardial ischemia due to ipsilateral subclavian artery stenosis in patients who have undergone coronary artery bypass graft. However, current knowledge of the optimal therapy for CSSS is limited. METHODS: The clinical data of 37 patients (33 male; mean age 65 ± 6 years) with CSSS who had undergone subclavian artery stenting between April 2007 and December 2015 were analyzed. RESULTS: The time elapsed between bypass surgery and the diagnosis of CSSS was 6.3 ± 4.3 years (median 5.2 years, range 1.3 months to 17.8 years). The technical success rate was 97.3% (100% for stenosis, 85.7% for occluded lesions). One patient experienced a transient ischemic attack; a second patient developed flow-limiting dissection involving the ostium of the internal mammary artery; and a third patient had a puncture site hematoma. The mean stenosis of target lesions decreased from 87.6 ± 10.6% to 5.9 ± 5.0% immediately after the procedure. A total of 35 (94.6%) patients were discharged with a complete remission of myocardial ischemia. During a follow-up of 44 ± 32 (range 6-112) months, no patient suffered from stroke or myocardial infarction. Stent-restenosis related unstable angina developing in one patient at 36 months and in another patient at 11 months, both of whom were relieved after balloon angioplasty and remained asymptomatic until the last follow-up. CONCLUSION: Subclavian artery stenting is feasible and safe in patients with CSSS, with a low incidence of perioperative complications and stent restenosis rate. © 2017 Wiley Periodicals, Inc.

Coronary Subclavian Steal Syndrome Successfully Treated with Subclavian Artery Stenting: A Report of 2 Cases.

Coronary subclavian steal syndrome (CSSS) is a well-recognized phenomenon secondary to coronary artery bypass grafting and may cause myocardial ischemia. We report 2 cases of CSSS successfully treated with subclavian artery (SA) stenting. In both cases, an Optimo balloon guiding catheter was placed in the SA immediately proximal to the vertebral artery (VA) origin as a double protection system for the VA and left internal thoracic artery (LITA) graft. There were no periprocedural complications. Balloon protection for both the VA and LITA using a single balloon guiding catheter is a reasonable and safe technique for preventing distal embolisms.

The value of exercise SPET for the detection of coronary artery steal syndrome secondary to unligated major side branch of left internal mammary artery.

OBJECTIVE: The clinical significance of unligated major left internal mammary artery (LIMA)-side branches (SB) remains controversial in patients with previous coronary artery bypass graft (CABG) surgery. The aim of this study was to investigate the clinical significance of unligated major LIMA-SB by using exercise myocardial perfusion imaging (MPI) with single-photon emission tomography. SUBJECTS AND METHODS: We conducted a retrospective analysis of 2819 consecutive patients who underwent diagnostic angiography. There were 407 CABG patients with LIMA graft. The demographic, laboratory, pre-angiographic stress test and angiographic data of these patients were collected. A subgroup of patients with unligated major LIMA-SB who were referred to angiography with the diagnosis of stable angina pectoris and positive exercise MPI was identified and divided into two groups for comparison: anterior wall vs non-anterior wall ischemia groups. RESULTS: Among 407 patients with LIMA graft, 112 (27.5%) patients were found to have unligated major LIMA-SB. In a subgroup of patients (n=45) with positive exercise MPI and patent LAD-LIMA system with unligated major LIMA-SB, the median values of diameter and length of unligated major LIMA-SB were statistically higher in anterior wall ischemia group (n=24) compared to non-anterior wall ischemia group (1.8mm vs 0.6mm, P<0.001 and 17.0cm vs 8.0cm, P<0.001, respectively). The cut-off values of unligated major LIMA-SB length and diameter were 11cm and 1.3mm respectively. Unligated major LIMA-SB with a length of ≥11.0cm and a diameter of >1.3cm had 95.8% of sensitivity and 100% of specificity for predicting anterior wall ischemia on exercise MPI. In patients with anterior wall ischemia, summed stress score and summed difference score were improved after percutaneous coil embolization of large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter. CONCLUSION: Large unligated major LIMA-SB with ≥11.0cm length and >1.3mm diameter seems to be a potential source of ischemia in CABG patients. We suggest that exercise MPI might be a first option noninvasive test in evaluating the clinical significance of unligated major LIMA-SB and the effectiveness of embolization therapy.

Stenting for left subclavian artery stenosis in patients scheduled for left internal mammary artery-coronary artery bypass grafting.

OBJECTIVES: To evaluate the early and long-term outcomes of stent placement for left subclavian artery stenosis (LSAS) in patients scheduled for left internal mammary artery-coronary artery bypass grafting (LIMA-CABG). BACKGROUND: Few studies have demonstrated the safety and effectiveness of endovascular therapy for the treatment of LSAS before LIMA-CABG; therefore, use of this therapy requires further exploration and evaluation. METHODS: Between February 2000 and April 2014, the clinical data of 167 consecutive patients (mean age 64 ± 9 years, 141 males) scheduled for LIMA-CABG with LSAS who were treated by stenting at the Fuwai Hospital were collected and analyzed retrospectively. RESULTS: The technical success rate of the procedure was 97.6% (163/167). The mean stenosis of target lesions decreased from 86.5 ± 9.9% to 7.6 ± 4.6% (P < 0.001). The incidences of death, stroke, and myocardial infarction, as well as the combined incidence of death, stroke, and myocardial infarction from the time of stenting to 30 days after the stenting procedure were 0.6% (n = 1), 1.8% (n = 3), 0% (n = 0), and 1.8% (n = 3), respectively. The 10-year rate of follow-up was 94.6%. The overall survival rate was 98.8% at 1 year, 97.5% at 2 years, 93.9% at 5 years, and 86.2% at 10 years. A total of 14.1% (23/163) of patients developed in-stent restenosis. Stent restenosis-related angina and myocardial infarction were observed in 13 and 3 patients, respectively. The patency rates of the left subclavian artery were 95.7, 93.8, 86.5, and 75.2% at 1, 2, 5, and 10 years, respectively. The target vessel reconstruction rate was 8.0% (13/163). CONCLUSIONS: Stenting of LSAS at experienced medical centers for patients scheduled for LIMA-CABG was safe and effective with a low incidence of complication and in-stent restenosis.

Left atrial myxoma causing coronary steal: an atypical cause of angina.

Cardiac myxomas are rare primary cardiac tumors that usually present with dyspnea or manifestations of systemic embolization. Coronary steal is a rare phenomenon of unbalanced blood flow that is seen primarily in patients who have undergone coronary artery bypass grafting and have subclavian artery stenosis. We report the case of a 72-year-old woman who presented with fatigue, weakness, and exertional chest heaviness and had abnormal results on a cardiac stress test. The results of coronary angiography showed no obstructive coronary artery disease but revealed a large intracardiac left atrial mass that was supplied by 2 anomalous coronary arteries. The patient underwent successful ligation of the anomalous coronary arteries and resection of the mass, which was histologically an atrial myxoma. The patient's symptoms resolved, and results of a repeat cardiac stress test were normal. To our knowledge, this is the first report of a highly vascularized atrial myxoma that caused coronary steal with objective evidence of ischemia, and with subsequent resolution after resection of the mass and ligation of the anomalous coronary arteries.

Coronary subclavian steal syndrome detected during coronary bypass surgery in a hemodialysis patient.

Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery.

Should dialysis-dependent patients with upper limb arterio-venous fistulae undergoing coronary artery bypass grafting avoid having ipsilateral in situ mammary artery grafts?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether dialysis-dependent patients with upper limb arterio-venous fistulae (AVFs) undergoing coronary artery bypass grafting should avoid having ipsilateral in situ internal mammary artery (IMA) grafts. A literature search performed yielded 28 peer reviewed articles, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The papers identified included 478 patients, of whom 219 had in situ IMA grafts with ipsilateral upper limb arterio-venous fistulae. There was a substantial variation between the papers, from single case reports to small retrospective cohort studies, but no randomized, controlled trials. The largest retrospective study included 155 patients and followed up for up to 5 years. Methods used to determine coronary steal included clinical assessment, electrocardiogram or echocardiographic changes, Doppler ultrasound of mammary arteries and angiography. The aggregate evidence suggested that 61 of the 219 patients with ipsilateral IMA grafts developed some clinical or physiological evidence of malperfusion during the use of the AVFs for dialysis. Comparisons with the contralateral IMA suggested that 27 of the 61 patients suffered similar problems when dialysis was applied. A number of studies used controls, including in situ right internal mammary artery (RIMA) flow and patients not on dialysis. In total, 32 patients had their in situ RIMA flow measurements studied, of which none showed any statistically significant flow alteration. While further strong evidence to demonstrate long-term outcomes is required, we recommend the avoidance, where possible, of ipsilateral in situ IMA grafts in patients with an upper limb AVF. There is sufficient experimental and anecdotal evidence to suggest that steal occurs and that in some patients, this has clinical implications on both morbidity and mortality. In this scenario, the use of the contralateral mammary is strongly advocated to maximize the patency of grafts in an already high-risk population.

Effect of arteriovenous hemodialysis shunt location on cardiac events in patients having coronary artery bypass graft using an internal thoracic artery.

The possibility of developing coronary steal in patients having coronary artery bypass graft (CABG) using internal thoracic artery (ITA) and ipsilateral upper extremity arteriovenous (AV) hemodialysis shunt has been reported. The impact of this phenomenon on clinical outcomes is uncertain. The aim of this study was to investigate an association between the AV dialysis shunt location regarding the side of the ITA CABG and clinical outcomes. This retrospective cohort study included chronic hemodialysis patients having ITA CABG and upper extremity AV shunt. The patients were divided into two groups: those with ipsilateral and those with contralateral location of ITA CABG and AV shunt. The outcomes were: death from any cause, cardiac death and a first cardiac event. In a group of 112 chronic hemodialysis patients having CABG, 32 had an ipsilateral and 25 had a contralateral location of ITA CABG and an upper extremity AV shunt. Significantly more cardiac events occurred in the group with an ipsilateral compared to a contralateral location of ITA CABGs and dialysis AV shunts (hazard ratio, 2.16 [95% CI, 1.11 to 4.19], P = 0.023). There was no difference between the groups in the all cause mortality risk (hazard ratio, 1.005 [95% CI, 0.43 to 2.37], P = 0.990) or the risk of cardiac death (hazard ratio, 2.43 [95% CI, 0.64 to 9.17], P = 0.191). The ipsilateral location of a CABG with the use of ITA and upper extremity AV hemodialysis shunt may be associated with increased risk of cardiac events.

Coronary subclavian steal from a left internal thoracic artery coronary bypass graft due to ipsilateral subclavian artery stenosis and an arteriovenous graft in a hemodialysis patient with left vertebral artery occlusion.

Coronary subclavian steal syndrome is an unusual cause of myocardial ischemia, secondary to a reversed blood flow in patients with patent internal thoracic artery coronary bypass grafts. The causes of coronary subclavian steal are either ipsilateral subclavian artery stenosis or upper extremity arteriovenous hemodialysis fistula formation or both. This report involves a 68-year-old woman with left vertebral artery occlusion who developed severe coronary steal in the absence of vertebral subclavian steal due to left subclavian artery stenosis and an arteriovenous hemodialysis graft.