Management of a Case of Severe Coronary Subclavian Steal Syndrome Twenty Years Post-Coronary Artery Bypass Graft in a Patient who Presented With Acute Myocardial Infarction

Abstract

The efficacy, safety, and long-term success of using the left internal mammary artery (LIMA) to bypass the left anterior descending artery (LAD) is well-established and is the most frequently used conduit for coronary artery bypass grafting (CABG) [ [1] Cua B. et al. Review of coronary subclavian steal syndrome. J Cardiol. 2017; 70: 432-437 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar ]. A left subclavian artery origin stenosis may progress enough to cause retrograde flow or ‘stealing’ of the myocardial blood supply via the LIMA graft to maintain left upper limb perfusion. This is known as Coronary Subclavian Steal Syndrome (CSSS) and its prevalence is likely underestimated [ [1] Cua B. et al. Review of coronary subclavian steal syndrome. J Cardiol. 2017; 70: 432-437 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar ]. This study described the successful management of a 72-year-old male with severe CSSS who presented with an acute myocardial infarction (AMI) 20 years following initial CABG. There is a lack of formal screening for left subclavian artery stenoses in both preoperative and postoperative CABG patients [ [1] Cua B. et al. Review of coronary subclavian steal syndrome. J Cardiol. 2017; 70: 432-437 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar ]. There is also a lack of consensus for intervention in this condition, with some sufferers of CSSS successfully managed conservatively [ [2] Angle J.F. et al. Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up. Vasc Endovasc Surg. 2003; 37: 89-97 Google Scholar ]. During coronary angiography, pressure-gradient measurements in one study showed a mean pre-treatment gradient of 29 mmHg [ [2] Angle J.F. et al. Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up. Vasc Endovasc Surg. 2003; 37: 89-97 Google Scholar ]. In this case, the patient had a pre-treatment gradient of 65 mmHg and left ventricular wall motion abnormalities. He received left subclavian artery stenting and was discharged on postoperative day 1, at which time he had a palpable radial pulse, he had no further myocardial infarctions.