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Coronary Subclavian Steal Syndrome
Eur J Vasc Endovasc Surg 27, 220–221 (2004) doi: 10.1016/j.ejvs.2002.10.001, available online at http://www.sciencedirect.com on
CASE REPORT
Coronary Subclavian Steal Syndrome C. D. Bicknell,* A. Subramanian and J. H. N. Wolfe Department of Vascular Surgery, St Mary’s Hospital, London W2 1NY, UK Inappropriate alterations in flow in the form of steal syndromes are a well recognised phenomenon. In the subclavian steal syndrome a proximal subclavian artery stenosis is responsible for reversal of flow in the vertebral artery and symptoms of vertebrobasilar ischaemia occur with arm movement. After internal mammary artery grafting to the coronary circulation, during coronary artery bypass surgery (CABG), coronary subclavian steal can occur. Retrograde flow occurs from the myocardium through the internal mammary graft to the subclavian artery secondary to a proximal subclavian stenosis. It is a rare but important cause of recurrent chest pain after coronary surgery. Key Words: Recurrent angina; Subclavian stenosis; Steal syndromes.
Case History A 69-year-old lady presented 6 years following coronary artery bypass grafting (CABG), details of which were unknown. Following surgery there had been an initial resolution of chest pain but typical angina symptoms returned after six months. These slowly progressed until she experienced angina on walking 100 yards despite treatment with a betablocker, calcium antagonist and long acting nitrate. Significantly she experienced chest pain on exercising the left arm. Examination demonstrated a full complement of supra aortic pulses with a left subclavian and left carotid bruit and revealed a significant difference of blood pressure between the arms (right 99/54, left 70/54). Arch angiography documented a stenosis in the 1st part of the subclavian artery (Fig. 1) with late filling of the vertebral artery and no filling of the left internal mammary artery (LIMA) graft. There was also a left internal carotid artery stenosis. Coronary angiography demonstrated triple native vessel coronary disease with two patent coronary grafts. The proximal stenosis of the left subclavian *Corresponding author. Colin Bicknell, Vascular Secretaries Office, Waller Cardiac Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK.
artery caused steal from the widely patent LIMA graft and the left vertebral artery. The patient was treated with angioplasty and stenting of the subclavian stenosis. There were no complications and the symptoms were immediately relieved: arm exercise no longer induced angina.
Discussion Coronary subclavian steal was first reported in 19741 and is now recognized with the increase of bypass surgery. The incidence is reported to be up to 3.4% after CABG.2 The patient with coronary subclavian steal syndrome describes a relapse after initial improvement following CABG and this may be associated with exercise of the left arm. Concurrent steal from vertebral and coronary circulations has been described.3 Examination may reveal differences in radial pulse volume and subclavian bruits. Discrepancies in blood pressure of the arms are suggestive of a subclavian stenosis but a normal blood pressure does not exclude the problem. Investigation by arch angiography remains the standard test for the proximal subclavian lesion. Angiography may demonstrate late filling of the vertebral artery due to retrograde flow from the circle
1078–5884/000220 + 02 $35.00/0 q 2003 Elsevier Ltd. All rights reserved.
Coronary Subclavian Steal Syndrome
221
used to restore adequate flow to the subclavian artery with relief of angina.5 Angioplasty of the subclavian artery was first described by Bachman and Kim in 19806 and angioplasty was first used in the treatment of the coronary subclavian steal syndrome to treat an unstable patient on intensive care with good results.7 There have been no trials directly comparing angioplasty to surgery in the treatment of subclavian stenosis. Prevention of this disease before the onset of symptoms has been advocated by some. Marques8 reports a group of 31 patients, most of whom were asymptomatic with a proximal subclavian stenosis. They underwent angioplasty of the left subclavian artery around the time of coronary surgery. Blood pressure in both arms remained similar in all but three patients during a mean follow up period of 3.1 years with only one patient developing recurrent angina symptoms.
References
Fig. 1. This figure shows an arch angiogram of a patient wth coronary subclavian steal syndrome after coronary artery bypass grafting. A catheter can be seen in the aorta proximal to the origin of the great vessels. A tight stenosis of the first part of the subclavian artery can be seen. There is no filling of the left vertebral artery or left internal mammary artery bypass graft.
of Willis and failure of contrast to enter the LIMA. Coronary angiography demonstrates filling of the left anterior descending artery and retrograde flow along the LIMA graft. Duplex Doppler scanning of the vertebral arteries can demonstrate subclavian steal from the vertebral arteries but visualization of the LIMA is difficult although possible.4 Both operative and radiological techniques can be
1 Harjola PT, Valle M. The importance of aortic arch or subclavian angiography before coronary revascularisation. Chest 1974; 73: 690 –693. 2 Lobato EB, Kern KB, Bauder-Heit J, Hughes L, Sulek CA. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2001; 15(6): 689 –692. 3 Giavroglou C, Proios T, Daponte P, Ioannidis I, Paraskevaidis S, Louridas G. Coronary-subclavian steal syndrome: treatment with percutaneous transluminal angioplasty and stent placement. Eur Radiol 1999; 9: 948 –950. 4 Sureyya Ozbek S, Paridlar M. Haemodynamic disorders in the internal thoracic artery: how are they associated with subclavian steal via ipsilateral vertebral artery. J Ultrasound Med 1998; 17(3): 147–151. 5 Takach TJ, Reul GJ, Gregoric I, Krajcer Z, Duncan JM, Livesay JJ, Cooley DA. Concomitant subclavian and coronary artery disease. Ann Thorac Surg 2001; 71(1): 187–189. 6 Bachman DM, Kim RM. Transluminal dilatation for subclavian steal syndrome. AJR 1980; 135(5): 995 –996. 7 Georges NP, Ferreti JA. Percutaneous transluminal angioplasty of subclavian artery occlusion for treatment of coronary subclavian steal. AJR 1993; 161(2): 399 –400. 8 Marques KM, Ernst SM, Mast EG, Bal ET, Suttrorp MJ, Plokker HW. Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary subclavian steal syndrome. Am J Cardiol 1996; 78(6): 687 –690. Accepted 15 October 2002
Eur J Vasc Endovasc Surg Vol 27, February 2004
CASE REPORT
Coronary Subclavian Steal Syndrome C. D. Bicknell,* A. Subramanian and J. H. N. Wolfe Department of Vascular Surgery, St Mary’s Hospital, London W2 1NY, UK Inappropriate alterations in flow in the form of steal syndromes are a well recognised phenomenon. In the subclavian steal syndrome a proximal subclavian artery stenosis is responsible for reversal of flow in the vertebral artery and symptoms of vertebrobasilar ischaemia occur with arm movement. After internal mammary artery grafting to the coronary circulation, during coronary artery bypass surgery (CABG), coronary subclavian steal can occur. Retrograde flow occurs from the myocardium through the internal mammary graft to the subclavian artery secondary to a proximal subclavian stenosis. It is a rare but important cause of recurrent chest pain after coronary surgery. Key Words: Recurrent angina; Subclavian stenosis; Steal syndromes.
Case History A 69-year-old lady presented 6 years following coronary artery bypass grafting (CABG), details of which were unknown. Following surgery there had been an initial resolution of chest pain but typical angina symptoms returned after six months. These slowly progressed until she experienced angina on walking 100 yards despite treatment with a betablocker, calcium antagonist and long acting nitrate. Significantly she experienced chest pain on exercising the left arm. Examination demonstrated a full complement of supra aortic pulses with a left subclavian and left carotid bruit and revealed a significant difference of blood pressure between the arms (right 99/54, left 70/54). Arch angiography documented a stenosis in the 1st part of the subclavian artery (Fig. 1) with late filling of the vertebral artery and no filling of the left internal mammary artery (LIMA) graft. There was also a left internal carotid artery stenosis. Coronary angiography demonstrated triple native vessel coronary disease with two patent coronary grafts. The proximal stenosis of the left subclavian *Corresponding author. Colin Bicknell, Vascular Secretaries Office, Waller Cardiac Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK.
artery caused steal from the widely patent LIMA graft and the left vertebral artery. The patient was treated with angioplasty and stenting of the subclavian stenosis. There were no complications and the symptoms were immediately relieved: arm exercise no longer induced angina.
Discussion Coronary subclavian steal was first reported in 19741 and is now recognized with the increase of bypass surgery. The incidence is reported to be up to 3.4% after CABG.2 The patient with coronary subclavian steal syndrome describes a relapse after initial improvement following CABG and this may be associated with exercise of the left arm. Concurrent steal from vertebral and coronary circulations has been described.3 Examination may reveal differences in radial pulse volume and subclavian bruits. Discrepancies in blood pressure of the arms are suggestive of a subclavian stenosis but a normal blood pressure does not exclude the problem. Investigation by arch angiography remains the standard test for the proximal subclavian lesion. Angiography may demonstrate late filling of the vertebral artery due to retrograde flow from the circle
1078–5884/000220 + 02 $35.00/0 q 2003 Elsevier Ltd. All rights reserved.
Coronary Subclavian Steal Syndrome
221
used to restore adequate flow to the subclavian artery with relief of angina.5 Angioplasty of the subclavian artery was first described by Bachman and Kim in 19806 and angioplasty was first used in the treatment of the coronary subclavian steal syndrome to treat an unstable patient on intensive care with good results.7 There have been no trials directly comparing angioplasty to surgery in the treatment of subclavian stenosis. Prevention of this disease before the onset of symptoms has been advocated by some. Marques8 reports a group of 31 patients, most of whom were asymptomatic with a proximal subclavian stenosis. They underwent angioplasty of the left subclavian artery around the time of coronary surgery. Blood pressure in both arms remained similar in all but three patients during a mean follow up period of 3.1 years with only one patient developing recurrent angina symptoms.
References
Fig. 1. This figure shows an arch angiogram of a patient wth coronary subclavian steal syndrome after coronary artery bypass grafting. A catheter can be seen in the aorta proximal to the origin of the great vessels. A tight stenosis of the first part of the subclavian artery can be seen. There is no filling of the left vertebral artery or left internal mammary artery bypass graft.
of Willis and failure of contrast to enter the LIMA. Coronary angiography demonstrates filling of the left anterior descending artery and retrograde flow along the LIMA graft. Duplex Doppler scanning of the vertebral arteries can demonstrate subclavian steal from the vertebral arteries but visualization of the LIMA is difficult although possible.4 Both operative and radiological techniques can be
1 Harjola PT, Valle M. The importance of aortic arch or subclavian angiography before coronary revascularisation. Chest 1974; 73: 690 –693. 2 Lobato EB, Kern KB, Bauder-Heit J, Hughes L, Sulek CA. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2001; 15(6): 689 –692. 3 Giavroglou C, Proios T, Daponte P, Ioannidis I, Paraskevaidis S, Louridas G. Coronary-subclavian steal syndrome: treatment with percutaneous transluminal angioplasty and stent placement. Eur Radiol 1999; 9: 948 –950. 4 Sureyya Ozbek S, Paridlar M. Haemodynamic disorders in the internal thoracic artery: how are they associated with subclavian steal via ipsilateral vertebral artery. J Ultrasound Med 1998; 17(3): 147–151. 5 Takach TJ, Reul GJ, Gregoric I, Krajcer Z, Duncan JM, Livesay JJ, Cooley DA. Concomitant subclavian and coronary artery disease. Ann Thorac Surg 2001; 71(1): 187–189. 6 Bachman DM, Kim RM. Transluminal dilatation for subclavian steal syndrome. AJR 1980; 135(5): 995 –996. 7 Georges NP, Ferreti JA. Percutaneous transluminal angioplasty of subclavian artery occlusion for treatment of coronary subclavian steal. AJR 1993; 161(2): 399 –400. 8 Marques KM, Ernst SM, Mast EG, Bal ET, Suttrorp MJ, Plokker HW. Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary subclavian steal syndrome. Am J Cardiol 1996; 78(6): 687 –690. Accepted 15 October 2002
Eur J Vasc Endovasc Surg Vol 27, February 2004