Summary
Objective
Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or—in addition with cerebral symptoms—in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS).
Method
We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks.
Results
A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case.
Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery.
Conclusion
The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.
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References
Angle JF, Matsumoto AH, McGraw JK, Spinosa DJ, Hagspiel KD, Tribble CG (2003) 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 Endovascular Surg 37(2):89–97
Berguer R, Morasch MD, Kline RA (1998) Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. J Vasc Surg 27(1):34–41
Chung DA, Large SR (2000) Relocation of the internal mammary artery graft in a case of coronary-subclavian steal. Thorac Cardiovasc Surg 48(1):39–40
Van Damme H, Caudron D, Defraigne JO, Limet R (1992) Brachiocephalic arterial reconstruction. Acta Chir Belg 92(1):37–45
Eisenhauer AC (2000) Subclavian and innominate revascularisation: surgical therapy versus catheter-based intervention. Curr Interv Cardiol Rep 2(2):101–110
Farina C, Mingoli A, Schultz RD, Castrucci M, Feldhaus RJ, Rossi P, Cavallaro A (1989) Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease. Am J Surg 158(6):511–514
Lobato EB, Kern KB, Bauder-Heit J, Hughes L, Sulek CA (2001) Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 15(6):689–692
Marshall WG, Miller EC, Kouchoukos NT (1988) The coronary-subclavian steal syndrome: report of a case and recommendations for prevention and management Ann Thorac Surg 46(1):93–96
Martinez-Dolz L, Sancheza E, Almenar L, Arnau MA, Osa A (2001) Refractory angina caused by subclaviancoronary steal syndrome treated with angioplasty and stent. Rev Esp Cardiol 54(7):920–923
Mehigan JT, Buch WS, Pipkin RD, Fogarty TJ (1977) A planned approach to coexisting cerebrovascular disease in coronary bypass candidates. Arch Surg 112(11):1403–1409
Minami K, Gawaz M, Ohlmeier H, Vyska K, Körfer R (1989) Management of concomitant occlusive disease of coronary and carotid arteries using cardiopulmonary bypass for both procedures. J Cardiovasc Surg 30:723–728
Nishio A, Takami T, Ichinose T, Masamura S, Hara M, Shimada K, Kamimori K, Narikawa T (2003) Percutaneous transluminal angioplasty and stent placement for subclavian steal syndrome with concomitant anterograde flow of the left internal mammary artery graft for coronary artery bypass-case report. Neurol Med Chir 43(10):488–492
Ochi M, Yamauchi S, Yajima T, Bessho R, Tanaka S (1997) Simultaneous subclavian artery reconstruction in coronary artery bypass grafting. Ann Thorac Surg 63(5):1284–1287
Rossum AC, Steel SR, Hartshorne MF (2000) Evaluation of coronary steal syndrome using sestamibiimaging and duplex scanning with observed vertebral subclavian steal. Clin Cardiol 23(3):226–229
Tyras DH, Barner HB (1977) Coronary-subclavian steal. Arch Surg 112(9):1125–1127
Tyagi S, Gambhir DS, Kaul UA, Verma P, Arora R (1996) A decade of subclavian angioplasty: aortoarteritis versus atherosclerosis. Indian Heart J 48(6):667–671
Vollmar J (1996) Aus: Rekonstruktive Chirurgie der Arterien, 4 Auflage. Georg Thieme, Stuttgart New York, S 290
Vollmar J (1996) Aus: Rekonstruktive Chirurgie der Arterien, 4 Auflage. Georg Thieme, Stuttgart New York, S 286
Wright IA, Laing AD, Buckenham TM (2004) Coronary subclavian steal syndrome: non-invasive imaging and percutaneous repair. Br J Radiol 77 (917):441–444
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Marquardt, F., Hammel, D., Engel, H.J. et al. The coronary-subclavian-vertebral steal syndrome (CSVSS). Clin Res Cardiol 95, 48–53 (2006). https://doi.org/10.1007/s00392-006-0312-7
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DOI: https://doi.org/10.1007/s00392-006-0312-7