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, 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.

Left Subclavian Artery Revascularization in Preparation for Coronary Artery Bypass Grafting.

Coronary subclavian steal syndrome is a rare but important condition that occurs after a left internal mammary artery (LIMA) to coronary artery bypass in the setting of a stenotic left subclavian artery. The lack of blood flow through the subclavian artery causes the reversal of flow in the LIMA so that it essentially steals blood from the myocardium. In order to avoid this complication, many surgeons now opt to either revascularize the stenotic subclavian artery prior to coronary artery bypass grafting or to use an alternate vessel as the bypass graft. Here, we present the case of an asymptomatic patient with poor exercise tolerance who was recently diagnosed with both triple-vessel coronary disease and peripheral arterial disease, which was most notably characterized by occlusion of the left subclavian artery. This case demonstrates the surgical management of this complex clinical entity.

Anatomic and clinical predictors of reintervention after subclavian artery stenting.

OBJECTIVE: This study was conducted to determine long-term predictors of target lesion reintervention (TLR) after subclavian artery stenting (SAS). METHODS: This was a single-center retrospective review of patients with symptomatic atherosclerotic subclavian artery disease who underwent SAS between January 1999 and December 2013. Repeat intervention was only performed in patients with recurrent symptoms and ≥70% in-stent restenosis (ISR). TLR was defined as need for a repeat percutaneous intervention involving a previously stented area. Freedom from events (ISR and TLR) was analyzed using Kaplan-Meier curves. Cox regression analysis was used to determine the significant predictors of TLR and ISR. RESULTS: Index procedures were performed on 139 arteries in 138 patients (69.6% female). Patients were an average age of 64.5 years, with major comorbidities of hypertension (80.4%), hyperlipidemia (72.5%), and tobacco use (60.1%). Also performed during the study period were 24 TLR procedures, resulting 166 SAS interventions attempted for patients with subclavian atherosclerotic disease during a 15-year span. Of 166 procedures, 163 (98.2%) were treated successfully. Stents were placed in all but two index arteries. The main indications for SAS were subclavian steal syndrome (48.9%), arm claudication (21.6%), and coronary steal syndrome (28.8%). The average preprocedure stenosis was 87.2% ± 11.2%. For index procedures (139 arteries), duplex follow-up was available for 134 arteries (96.4%), with an overall ISR rate of 18.7% (25 of 134). Primary patency for the index procedures was 84.7% at 10 years. The overall TLR rate for the index procedures was 12.7% (17 cases). Seven patients required more than one secondary procedure. For all cases, the freedom from ISR was 91%, 77%, and 68% at 1, 5, and 10 years, respectively, and freedom from TLR was 94%, 85%, and 82% at 1, 5, and 10 years, respectively. Multivariate analysis showed the significant predictors of ISR were smoking/chronic obstructive pulmonary disease (hazard ratio [HR], 3.2; P = .001), age by decade (HR, 0.5; P < .001), discharged with statin therapy (HR, 0.3; P = .001), vessel diameter ≤7 mm (HR, 2.3; P = .028), and right-sided intervention (HR, 0.3; P = .040). The sole significant predictor of TLR was age by decade (HR, 0.6; P = .008). CONCLUSIONS: SAS has a high primary success and durability with satisfactory outcomes well beyond 10 years. ISR was more likely to develop in patients who were smokers with chronic obstructive disease or had a baseline vessel size of ≤7 mm. Younger age could be an independent risk factor for secondary intervention.

Coronary subclavian steal syndrome: a case-based review.

Internal mammary artery (IMA) grafts have been shown to be superior to saphenous vein grafts in terms of rare atherosclerotic involvement, biochemical and physical qualities, and long-term patency rates. The IMA originates from the subclavian artery, just distal to the vertebral artery, and an occlusion or a hemodynamically significant stenosis proximal to the IMA ostium would cause a pressure drop distally and a reversal of flow from the coronary arteries to the IMA in patients with this graft. This condition is referred to as "coronary subclavian steal syndrome" (CSSS). In most cases, the cause of this syndrome is atherosclerotic disease; however, other causes of subclavian artery stenosis (SAS) have the potential to lead to CSSS. Patients with CSSS present with the symptoms of myocardial ischemia due to coronary steal, vertebrobasilar insufficiency, or limb ischemia. Discrepancy in the blood pressure (BP) measurements in two arms should warn the clinician of SAS. A diminished pulse or the bruit of jet flow on the lesion side can be noticed. Doppler ultrasonography, computed tomography angiography, and magnetic resonance angiography are safe and accurate noninvasive modes of diagnosis. Treatment can be surgical or percutaneous.

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.

Subclavian artery stenosis: a case series and review of the literature.

Subclavian artery stenosis (SAS) is a significant form of peripheral artery disease, which may be a marker of diffuse atherosclerosis and increased risk for cardiovascular events. SAS can lead to symptomatic ischemia affecting the upper extremities, the brain, and, in some cases, the heart. In general, asymptomatic subclavian artery disease is treated with medical therapy and invasive treatment is reserved for the more symptomatic patients. This article discusses the evaluation of four patients with varying presentations of subclavian artery disease.

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.

[Percutaneous closure of the coronary artery-pulmonary artery fistula in a patient with apical hypertrophic cardiomyopathy]. / Apikal hipertrofik kardiyomiyopatili bir hastada koroner arter ile pulmoner arter arasindaki fistülün perkütan yolla kapatilmasi

A fifty-four-year-old female patient was admitted to our unit with exertional chest pain of six months duration. Transthoracic echocardiography showed apical hypertrophy. Upon further investigation, cardiac magnetic resonance imaging revealed apical hypertrophic cardiomyopathy. The patient underwent myocardial perfusion scintigraphy which showed anterior ischemia. Coronary angiography revealed an arteriovenous fistula (AVF) from the left anterior descending artery to the pulmonary artery. The patient's chest pain was attributed to a coronary steal syndrome secondary to the coronary AVF. The AVF fistula was closed with a coil and the patient's chest pain improved. In conclusion, coronary steal syndrome may lead to myocardial ischemia in patients with a coronary AVF.

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.

[Coronary-subclavian steal syndrome, a complication following surgical revascularization of myocardium]. / Koronární-subklaviální steal syndrom, komplikace po chirurgické revaskularizaci myokardu.

Coronary-subclavian steal syndrome (CSS) is defined as a reversal of flow in a previously constructed internal mammary artery coronary conduit, producing myocardial ischemia. The most often cause is a proximal subclavian artery stenosis or closure. For the first time was CSS described in 1974 and initially was believed to be rare. However, today is the internal mammary artery to the left anterior descending coronary artery used in cardiosurgery as a standard and we can see increasing documentation of this phenomenon. A case report is presented and possibilities of management are discussed in the article.

[Coronary-subclavian steal syndrome]. / Síndrome de roubo subclávio-coronário.

OBJECTIVE: Presentation of 3 consecutive cases of coronary-subclavian steal syndrome, with special attention to clinical evolution, diagnosis, treatment strategies and outcomes. MATERIAL AND METHODS: We present three consecutive cases of male patients, aged 60 to 69 years (average: 63 years) with hypertension, dyslipidemia, and smoking as the most prevalent cardiovascular risk factors. The 3 cases had a history of previous coronary revascularization using the left internal mammary artery to the anterior descending coronary, with an interval of 4 months to 4 years before the onset of symptoms, 2 of the cases with stable angina, 1 with V4 to V6 ST segment depression in the exercise test and 1 with myocardial infarction with no ST segment elevation. None of the patients had left upper limb claudication. In 2 patients, no left radio-cubital pulse was detected at rest being weak in the third. All patients had atherosclerotic obliteration of the left subclavian artery, 2 with occlusion and 1 with stenosis >90%. Cardiac catheterization was the diagnostic exame in all cases. The interval between diagnosis and intervention was 6 to 13 weeks (median of 9 weeks). We chose the endovascular treatment with balloon expandable stent. The preferred access route was the left humeral artery in 2 cases and the femoral artery in the third. RESULTS: In all patients the revascularization was achieved, without residual stenosis. Angiography after revascularization, disclosed antegrade flow in all patients through the left internal mammary artery. Recovery of the symmetry of pulses was noticed in all the patients, no signs or symptoms of myocardial ischemia were presented in two of them, with nonspecific pre-cordial symptoms remained in the third, after effort. All patients were discharged with dual antiplatelet therapy for a period not less than 3 months. CONCLUSION: The coronary-subclavian steal syndrome is a rare cause of myocardial ischemia after coronary revascularization (0.1% to 6%), as a result of proximal arterial occlusive disease, with subsequent hemodynamic, being atherosclerosis the main etiology. Although the surgical route has been the treatment of choice in the past, endovascular revascularization emerged nowadays as the first-line treatment, with recent studies demonstrating high patency at the 2nd and 5th year after angioplasty (100% and 85% to 95%) and low morbidity and mortality. Further doubts arise about the role of double antiplatelet therapy, having been chosen, in this series, treatment of at least 3 months.

Don't Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome.

Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.

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.

Review of coronary subclavian steal syndrome.

The clinical benefits of using the left internal mammary artery (LIMA) to bypass the left anterior descending artery are well established making it the most frequently used conduit for coronary artery bypass surgery (CABG). Coronary subclavian steal syndrome (CSSS) occurs during left arm exertion when (1) the LIMA is used during bypass surgery and (2) there is a high grade (≥75%) left subclavian artery stenosis or occlusion proximal to the ostia of the LIMA resulting in "stealing" of the myocardial blood supply via retrograde flow up the LIMA graft to maintain left upper extremity perfusion. Although CSSS was once thought to be a rare phenomenon, its prevalence has been underestimated and is becoming increasingly recognized as a serious threat to the success of CABG. Current guidelines are lacking on recommendations for screening of subclavian artery stenosis (SAS) pre- and post-CABG. We hope to provide an algorithm for SAS screening to prevent CSSS in internal mammary artery bypass recipients and review treatment options in the percutaneous era.

Drug coated balloon angioplasty for subclavian artery stenosis: A potential novel indication.

Subclavian artery stenosis is associated with increased cardiovascular disease mortality. It remains an important treatable cause of upper extremity, brain and cardiac ischemia. Endovascular treatment with angioplasty and stenting has become the preferred modality of treatment. Surgical revascularization is reserved for difficult cases with unfavorable anatomy to endovascular approach. Here we describe a case of subclavian artery stenosis causing subclavian steal syndrome with unfavorable anatomy to stenting treated successfully with drug coated balloon angioplasty with maintenance of patency at 6months.