Coronary Subclavian Steal Syndrome Research Articles

Surgical treatment of coronary subclavian steal syndrome

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Intraoperative presentation of coronary subclavian steal syndrome during coronary artery bypass surgery: a case report

Intraoperative presentation of coronary subclavian steal syndrome during coronary artery bypass surgery: a case report

Long-Term Outcome of Carotid-Subclavian Bypass in the Management of Coronary-Subclavian Steal Syndrome.

The presence of a significant left subclavian artery stenosis may occasionally lead to blood flow reversal through a LIMA-to-coronary artery bypass graft during left arm exertion; with "stealing" of myocardial blood supply. The aim of this study was to review our experience with carotid-subclavian bypass in patients with post-CABG coronary-subclavian steal syndrome. This is a retrospective review of all patients who underwent carotid-subclavian bypass grafting for post-CABG coronary-subclavian steal syndrome at Mainz University Hospital between 2006 and 2015. Cases were identified in our institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records. Nine patients (all males, mean age of 69.1years) underwent surgical treatment for post-CABG coronary-subclavian steal syndrome. Medium interval between original CABG and carotid-subclavian bypass grafting was 86.1months. There were no perioperative deaths, strokes or myocardial infarctions. At a mean follow-up period of 79.9months, all patients remained asymptomatic and all carotid-subclavian bypass grafts remained patent. One patient required stenting of a common carotid artery stenosis proximal to the graft anastomosis site, and coronary artery stenting was required in four patients in regions other than those supplied by the patent LIMA graft. Carotid-subclavian bypass surgery is a safe treatment option even in patients with multivessel disease and severe comorbidities and should be taken into consideration in patients who are deemed fit for surgery and those who would benefit from the excellent long-term patency rates.

Feasibility of Intravascular Lithotripsy for the Treatment of Calcified Supra-Aortic Vessels: A Case Report and Literature Review.

To report a case of coronary-subclavian steal syndrome (CSSS) due to a history of a left internal mammary artery (LIMA) to left anterior descending (LAD) artery coronary bypass (CABG) and a heavily calcified ostial left subclavian artery (LSA) occlusion, that was treated with intravascular lithotripsy (IVL) technique and to summarize the current trends of IVL treatment for supra-aortic vessels. A 64-year-old woman with progressive intermittent angina pectoris and a history of LIMA to LAD bypass underwent coronary angiography which demonstrated complete ostial occlusion of the LSA. Via brachial access, the patient underwent Shockwave IVL balloon treatment of the LSA and stent-graft implantation. At 9 months follow-up, the patient showed symptoms resolution, and duplex ultrasound (DUS) demonstrated a patent LSA. The Shockwave IVL system was demonstrated to be a feasible treatment and justified for selective cases of highly calcified lesions in supra-aortic vessels. The present case report and the literature review, in a total of 47 patients resulted in a high technical procedural success rate, with a low rate of complications. Future studies with larger cohorts are warranted to confirm these findings and standardize this technology in this particular vascular field. The present study exemplifies a case of recanalization of the left subclavian artery in a patient with coronary-subclavian steal syndrome with a heavily calcified ostial lesion treated with intravascular lithotripsy (IVL). In this paper, for the first time, a review of the contemporary literature on the use of IVL in supra-aortic vessels is reported, elucidating the feasibility of this technique in this vascular territory. Despite the heterogeneous features of the reported cases and the lack of a standardized protocol for the use of IVL in the management of highly calcified lesions of supra-aortic vessels, it was demonstrated to be a feasible technique, with a high technical success rate, being an advantageous tool for heavily calcified supra-aortic lesions.

Utility of supra-aortic doppler ultrasound for the diagnosis of coronary subclavian steal syndrome

Utility of supra-aortic doppler ultrasound for the diagnosis of coronary subclavian steal syndrome

Abstract 10148: Prevalence, Clinical Characteristics and Cardiovascular Outcomes of Acute Coronary Syndrome Attributable to Coronary Subclavian Steal Syndrome in Patients with a History of Coronary Artery Bypass Grafting

Introduction: Coronary subclavian steal syndrome (CSSS) is coronary steal phenomenon due to subclavian artery stenosis (SAS) in patients with a history of CABG using internal mammary artery (IMA). While CSSS could cause acute coronary syndrome (ACS), its frequency, clinical characteristics and cardiovascular outcomes remain unknown. Methods: The current study was a retrospective multi-center analysis of 142 ACS patients who previously received CABG from January 2007 to October 2020. CSSS was defined as myocardial ischemia due to SAS. Clinical characteristics and cardiovascular events (=cardiac-cause death + myocardial infarction + stroke) were compared in subjects with and without CSSS. Results: CSSS was identified in 7.0% (=10/142) of study subjects. Of these, 1, 6 and 3 CSSS cases had SAS at right, left and both subclavian arteries, respectively. The averaged pressure gradient at SAS site was 31±13mmHg. ACS subjects attributable to CSSS were more likely to exhibit NSTEMI (90% vs. 52%, p=0.02), a history of hemodialysis (40% vs. 14%, p=0.03) and peripheral artery disease (70% vs. 20%, p<0.001). Of note, all of 4 CSSS subjects receiving hemodialysis had their arterial-venous fistula at the same side of SAS. With regard to revascularization procedure in CSSS subjects, primary endovascular treatment for SAS was performed in only 2 cases. Furthermore, despite SAS as a culprit lesion of ACS, primary PCI for native coronary lesion was conducted in other 6 cases. As a consequence, most of them (=5/6) required additional revascularization of SAS after primary PCI due to unresolved myocardial ischemia or chest pain. During 50-month observational period, CSSS was associated with a greater likelihood of cardiovascular (p=0.003) and stroke events (p<0.001, Figure). Conclusions: A substantially elevated cardiovascular risk was observed in ACS patients attributable to CSSS. This finding suggests clinical needs to meticulously evaluate SAS before and after CABG using IMA.

Abstract 9524: The Challenge of Treating a Previously Surgical Revascularized Patient With Acute ST-Elevation Myocardial Infarction (STEMI) and Coronary-Subclavian Steal Syndrome

Introduction: Coronary-subclavian steal syndrome (CSSS) is a rare cause of myocardial ischemia after coronary artery bypass grafting (CABG), due to significant stenosis of the proximal portion of the left subclavian artery. It is characterized by blood flow inversion in the left internal thoracic artery, diverting the blood flow from the coronary artery to the left medio-distal subclavian artery. We report a case of a patient who underwent complex surgery to correct the CSSS. Case report: A 70-year-old male patient, with history of both percutaneous coronary intervention (PCI) of the right coronary artery and CABG, was admitted to the emergency room with STEMI and complete atrioventricular block. He was initially managed to the cath lab where a transvenous pacemaker was implanted and coronary angiography showed occlusion of the left main, proximal right coronary and left subclavian arteries. Only saphenous vein - second marginal graft was patent and, despite severe stenosis in the proximal portion of the circumflex artery, this artery was responsible for irrigation of the entire left coronary system, as well as retrograde filling of the left internal thoracic artery - anterior descending artery graft. A conservative approach was proposed. For a better anatomically interpretation, coronary angiotomography was indicated and showed obstruction of the left subclavian artery after its origin, with 2.2cm length and refilling before the origin of the ipsilateral vertebral and internal mammary arteries. In addition, most visceral branches demonstrated severe atherosclerosis, and the right common iliac artery and left external iliac artery were occluded. After discussion with the Heart Team, it was decided to perform a left carotid-subclavian graft with a segment of the saphenous vein. The procedure was successful, with no complications and lasted 5 hours. The patient was discharged from hospital one week later. Discussion: CSSS is rare and difficult to treat. The most common treatment is angioplasty of the subclavian artery, which was not possible in this case due to the lack of femoral access and the extension of the occlusion. In this patient, with a high risk of death, the bypass surgical revascularization with saphenous graft became the only feasible treatment.

Atypical and rare cause of myocardial infarction: coronary subclavian steal syndrome (CSSS) treated by a carotid-subclavian bypass in a 71-year-old female patient

BackgroundThe coronary subclavian steal syndrome (CSSS) is a rare complication after coronary arterial bypass graft operations (CABG) using the left or right internal mammary artery ((L/R)IMA). It results from a retrograde blood flow from the IMA into the subclavian artery (SA) due to a stenosis or occlusion of the SA proximal to the IMA origin. This “steal phenomenon” leads to a decreased blood flow in the IMA and may result in myocardial ischemia (MIS) and even myocardial infarction (MIN). Treatment options include interventional and surgical therapy.Case presentationWe report the case of a 71-year old woman, who suffered from an acute non-ST elevation myocardial infarction (NSTEMI) 11 years after LIMA-CABG surgery and who was treated successfully with a carotid-subclavian bypass (CSB) after failed interventional therapy.ConclusionCSB may be regarded as a viable treatment option for patients suffering CSSS in the case of MIS and even an acute MIN/NSTEMI, especially in the case of missing or failed interventional therapy attempts. Specialists in cardiothoracic and vascular surgery should be aware of possible CSSS conditions and know about appropriate diagnostic and therapeutic options.

Atrial fibrillation as a contributing factor in the diagnostic algorithm for coronary subclavian steal syndrome and cardiac tamponade following coronary artery bypass graft surgery: a case study

Coronary subclavian steal syndrome (CSSS) is a complication of coronary artery bypass graft (CABG) surgery in patients with coexistent significant subclavian artery stenosis (SAS). It is characterized by a retrograde blood flow through the left internal mammary artery graft from the coronary to subclavian circulation, leading to myocardial ischemia. Current screening for CSSS includes bilateral blood pressure measurement for the detection of a significant inter-arm blood pressure difference. However, the commonly used automated sphygmomanometers have limited accuracy in patients with atrial fibrillation. Consequently, these patients are often underdiagnosed. We present a case of a 73-year-old man with a medical history of atrial fibrillation, peripheral artery disease, and CABG surgery four months before the current event, who came to the emergency department due to progressive dyspnea. The initial diagnostic management showed a large circulatory pericardial effusion, so the patient was admitted to the coronary care unit and underwent pericardial drainage. In the following days, due to a sudden high increase in cardiac troponin, the patient underwent an urgent coronary angiography, which revealed severe left SAS with functional CABG, indicating the occurrence of CSSS. Percutaneous transluminal angioplasty was then performed with an optimal angiographic result. The patient was discharged in good condition with adequate medicament therapy and instructions. This case report highlights atrial fibrillation as a contributing factor for the diagnosis of CSSS and pericardial tamponade after CABG surgery. Furthermore, we suggest a diagnostic approach that can reduce the incidence of both these severe complications.

Coronary subclavian steal syndrome: A case report

Coronary subclavian steal syndrome: A case report

P219 The role of color-coded duplex sonography in evaluating coronary-subclavian steal syndrome

Abstract Background Coronary-subclavian steal syndrome is a rare phenomenon leading to dysfunction of left internal mammary artery (LIMA)-graft after coronary artery grafting with the occurrence of proximal stenosis of the left subclavian artery (LSA), which causes myocardial ischemia due to a blood-steal phenomenon through a fully patent LIMA-graft. Purpose To evaluate the role of color-coded duplex sonography (CCDS) in follow-up of all symptomatic patients with LIMA-graft after aorto-coronary bypass grafting (ACBG). Methods Two men and one woman with recurrence of angina pectoris symptoms and vertigo after ACBG with LIMA-LAD graft. Patients were hospitalized in cardiology for coronary graft assessment via selective coronary arteriography. Due to the discovery of fully patent grafts with a combination of varying degrees of proximal stenosis of the LSA, CCDS with a high-frequency linear probe was used to evaluate cervical arteries, LSA and the LIMA-graft flow rate applying functional probe for hyperemia (PH) of the left upper limb for hemodynamic assessment of significance of the steal syndrome. Results One woman at age 72 after ACBG – LIMA-LAD; RM1; RCA -s.v.g. Selective coronary arteriography showed patent bypass grafts with 70% proximal stenosis of LSA. The performed CCDS showed a LIMA-graft blood flow reduction from 36 ml/min to 12 ml/min in a sample for left upper limb hyperemia. There was a difference in the blood pressure of the upper limbs within 20 mmHg. Dobutamine stress echocardiography was performed, confirming ischemic zones in the LAD- peak segments. A 63 year old man after ACBG x 4 with a difference in blood pressure of upper limbs within 40 mmHg. The performed CCDS showed thrombosis of the left internal carotid artery, high-grade stenosis of the right internal carotid artery, high-grade stenosis of LSA, alternating blood flow in the left vertebral artery – a sign of hemodynamically significant steal syndrome. A 65 year old male after ACBG x 3 (LIMA-LAD, RCA, OM1 -s.v.g.). The selective coronary arteriography showed patent LIMA-graft with 50% proximal stenosis of LSA with a trans-stenotic pressure gradient of 20 mmHg. To identify the steal phenomenon we used CCDS, which showed a blood flow reduction into the LIMA-graft from 14.2 ml/min to 7.5 ml/ min - data of hemodynamically significant steal syndrome. Patients were treated with percutaneous transluminal angioplasty and stenting of the LSA with postprocedure reduction of angina pectoris complaints, no difference in the blood pressure of upper limbs and no reduction of LIMA-graft blood flow during the probe for hyperemia of the upper limb. Conclusion(s) Color-coded duplex sonography is an important and indispensable technique, part of the overall assessment of hemodynamics in case of coronary-subclavian steal syndrome and probably may prove to be a first method of choice in follow-up of all symptomatic patients with LIMA-LAD graft.

Coronary subclavian steal syndrome.

Coronary subclavian steal syndrome.

CAR 11. Rare Supra-aortic Steal Syndromes—Endovascular Approach

Supra-aortic vessel occlusive disease can rarely be manifested as steal syndrome. Innominate steal syndrome is the reversal of flow in the right carotid artery due to stenosis or occlusion of the innominate artery. Coronary-subclavian steal syndrome (CSSS) can occur in patients with internal mammary artery (IMA)-coronary artery bypass graft because of significant ipsilateral subclavian artery stenosis resulting in reversed blood flow from the myocardium to the upper limb. We report two cases of innominate steal syndrome and CSSS and present a literature review. Case 1: A 64-year-old man was admitted with dizziness, nausea, paresthesia, and claudication in the right arm of 48 hours’ evolution. Head computed tomography excluded acute ischemic lesions. Color duplex ultrasound examination revealed severe stenosis of the innominate artery (peak systolic velocity of 384 cm/s), occlusion of the right vertebral artery, and total flow inversion of the right internal carotid artery. Computed tomography angiography confirmed a preocclusive stenosis of the innominate artery. Puncture of the right brachial artery and exposure of the right common carotid artery were performed. Brain protection was achieved by direct clamping of the common carotid artery. A kissing stent technique was performed with balloon-expandable stents. Direct expulsion of eventual embolic material was performed before declamping. The postoperative period was uneventful without recurrence of symptoms. Case 2: A 61-year-old woman was submitted to coronary artery bypass grafting of the left IMA to the left anterior descending artery and a venous graft to the marginal artery 9 years earlier. The patient remained asymptomatic until 3 months earlier, when she developed chest pain on exertion, particularly when using the left arm. Computed tomography angiography revealed a critical stenosis at the proximal left subclavian artery, without apparent lesions on the venous graft or IMA graft. Under local anesthesia, primary stenting of the lesion was performed. Control angiography showed a fast flow without residual stenosis of the left subclavian artery and good visualization of the IMA graft and left vertebral artery. At 6-month follow-up, the patient remained asymptomatic and without restenosis on color duplex ultrasound. Although rare, supra-aortic vessel steal syndromes can lead to disabling strokes and to life-threatening conditions, especially CSSS. These case reports highlight the importance of color duplex ultrasound in diagnosis and the feasibility of the endovascular approach.

A rare case of non-ST-segment elevation myocardial infarction triggered by coronary subclavian steal syndrome.

A rare case of non-ST-segment elevation myocardial infarction triggered by coronary subclavian steal syndrome.

Coronary steal phenomenon in post CABG patients

Encountering a coronary subclavian steal syndrome phenomenon is a rare opportunity. We came across three such cases. Article describes unique cases of two elderly males and one female who underwent CABG few years ago and presented with recurrent chest pain symptoms.

WHY STEAL FROM ONE WHEN YOU CAN STEAL FROM TWO: A UNIQUE CASE OF CLASSIC SUBCLAVIAN STEAL SYNDROME WITH CONCOMITANT CORONARY SUBCLAVIAN STEAL SYNDROME IN THE POST CORONARY BYPASS PATIENT

Subclavian steal syndrome (SSS) involving both vertebral and bypass arteries in the post-CABG patient is poorly described in the literature. Cases of coronary subclavian steal syndrome (CSSS) in the post-CABG patient traditionally require repeat open thoracic surgery or percutaneous intervention via

CORONARY ARTERY SUBCLAVIAN STEAL SYNDROME WITH DILATED LEFT INTERNAL MAMMARY ARTERY

Coronary artery subclavian steal syndrome has an incidence of 0.2-0.7%. First described in 1974 by Harjola and Valle, it results from >70% stenosis of the proximal subclavian artery, most commonly due to atherosclerotic disease. This results in lower pressure gradient in the distal subclavian artery

Our experience of endovascular treatment in coronary subclavian steal syndrome with a review of the literature

Aim: The purpose of this study was to assess the effectiveness of endovascular treatment in patients with coronary subclavian steal syndrome. Material and Methods: The archive records for six patients diagnosed with coronary subclavian steal syndrome and treated using the endovascular method between January 2012 and August 2017 were examined retrospectively. Data concerning diagnosis and treatment were recorded and evaluated in the light of the current literature. Results: All patients had undergone coronary artery bypass graft surgery at external centers a mean 5.7 years previously. Angiography revealed severe stenosis in the proximal subclavian artery in three patients and total occlusion in three. One hundred percent success was achieved in the three patients with stenosis by establishing full patency by means of a stent procedure. Full patency was also established in two of the three patients with total occlusion using the stent procedure. The symptoms of the five patients treated successfully resolved post-procedurally. No restenosis findings were encountered at clinical and Doppler ultrasonography followups. Conclusion: While surgical options predominated in the early years in the treatment of coronary subclavian steal syndrome, endovascular techniques are widely employed today. However, surgical therapeutic alternatives are still important for patients in whom success cannot be achieved with the endovascular method.

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

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.

Coronary Subclavian Steal Syndrome: Diagnosis by Routine Chest Computed Tomography and Percutaneous Treatment with Subclavian Artery Stenting

Coronary Subclavian Steal Syndrome: Diagnosis by Routine Chest Computed Tomography and Percutaneous Treatment with Subclavian Artery Stenting