ORIGINAL CONTRIBUTIONS

Percutaneous Treatment of Coronary Subclavian Steal Syndrome

Niall T. Mulvihill, MD, Mohamed Loutfi, MD, Emmanuel Salengro, MD, Marco Boccalatte, MD, Jean Claude Laborde, MD, Jean Fajadet, MD, Jean Marco, MD
Niall T. Mulvihill, MD, Mohamed Loutfi, MD, Emmanuel Salengro, MD, Marco Boccalatte, MD, Jean Claude Laborde, MD, Jean Fajadet, MD, Jean Marco, MD
Coronary subclavian steal syndrome is a variant of subclavian steal syndrome. It consists of obstructive atherosclerotic disease of the proximal subclavian artery in the presence of a patent internal mammary artery that has been previously used as an arterial conduit for a coronary artery bypass procedure.1,2 The reduction in antegrade flow caused by proximal subclavian arterial obstruction can produce either symptomatic or silent myocardial ischemia in the territory subtended by the graft as well as other non-cardiac symptoms and signs typical of subclavian steal syndrome.3–5 The majority of patients require either surgical6–8 or percutaneous treatment9–11 to alleviate the symptoms. There have been a variety of surgical procedures described to tackle this problem and the choice depends on whether the diagnosis is made before or after coronary surgery. If a subclavian stenosis is known prior to coronary bypass surgery, coronary surgery can be combined with direct subclavian artery bypass.12 If surgical treatment is required at some time after coronary surgery, extra thoracic subclavian artery bypass can be performed.8 However, the surgical procedures are associated with a small but significant risk of stroke and mortality even when using less invasive extra-anatomic extrathoracic reconstructions.13 In recent years, a percutaneous approach has been adopted to deal with subclavian steal as well as coronary subclavian steal syndromes.9 The reported initial and long-term success rates of percutaneous techniques compare favorably with surgery. We describe our experience and results of the percutaneous treatment of 6 consecutive patients with coronary subclavian steal syndrome.

Methods

We identified 6 symptomatic patients with concomitant coronary and subclavian arterial atherosclerotic disease. Five patients had previously undergone coronary artery bypass surgery utilizing at least 1 internal mammary artery graft (Figures 1A and 1B). The other was scheduled for coronary revascularization surgery (Figures 2A and 2B). There were 4 male and 2 female patients and the average age was 66 ± 14 years. Three patients were diabetic and 4 had hypertension. All 6 patients presented because of symptoms of coronary ischemia and had evidence of reversible ischemia on non-invasive testing, i.e., exercise stress testing (4/6) and reversible deficits on perfusion scanning (2/6). Only 3 of the 6 patients had a recorded difference in mean arterial blood pressure (> 10 mmHg) between the right and left arm. Some clinical and angiographic details are outlined in Table 1.

Results

The subclavian artery stenosis was confirmed angiographically in all cases. The target stenosis was located in the left subclavian artery in 4 cases and in the right subclavian artery in the other 2 cases. Intravenous heparin 3,000–6,000 IU was administered intravenously during the procedure. Subclavian artery angioplasty was performed in an antegrade fashion in all cases from the femoral artery using 8 Fr guiding catheters. Balloon predilatation was performed in all 6 cases and single stent implantation was successfully performed in all cases. The mean balloon diameter was 7.8 mm (range, 7–9 mm). Two patients received Medtronic AVE stents, two Palmaz Schatz stents and two Herculink stents. The angiographic success rate was 100% (Discussion In coronary subclavian steal, there is a stenosis of the proximal portion of the subclavian artery resulting in reversal of flow in an internal mammary artery graft and subsequent ischemia in the territory it supplies. The subclavian arterial stenosis produces a negative pressure gradient between the subclavian and internal mammary artery graft. Subsequent retrograde filling of the subclavian artery via the internal mammary graft causes the subclavian to “steal” blood from the coronary circulation. The prevalence of subclavian artery stenosis in patients undergoing coronary revascularization varies from 0.5–1.1%.14 Similarly, patients who undergo axillofemoral bypass surgery may have persistent symptoms or graft failure due to a previously unrecognized subclavian artery stenosis. Percutaneous treatment of subclavian artery stenosis is less invasive, has lower complication rates and has a shorter hospital stay than surgical treatment. Both the immediate results and the long-term outcomes after balloon dilatation and stenting for stenotic lesions are excellent.15 However, when treating occluded subclavian arteries it is preferable to use a stent, since the restenosis rates of simple balloon dilatation remain high.16 The published reports of percutaneous treatment of coronary subclavian steal syndrome reveal excellent technical success rates with good long-term clinical benefit.12,17,18 Although surgical treatment remains feasible, percutaneous revascularization of the subclavian artery both proximal and distal to the origin of the vertebral artery is now the treatment of choice in the management of subclavian steal syndromes.9 Subclavian artery stenting can preserve internal mammary artery flow both prophylactically and therapeutically in aortocoronary bypass patients, as demonstrated in our series. A small increase in the lumen size results in significantly improved antegrade blood supply and amelioration of ischemic symptoms.19 Distal embolization is a concern during treatment, but Ringlestein et al. demonstrated by Doppler ultrasound that reversal of flow from retrograde to antegrade in vertebral arteries following subclavian artery angioplasty develops gradually over a period varying between 20 seconds to several minutes.20 It has been hypothesized that this protective mechanism prevents distal embolization to the posterior fossa. Atherosclerotic disease of subclavian and coronary arteries giving rise to coronary subclavian steal syndrome can be successfully treated percutaneously with excellent immediate and long-term success.
References
1. Breall JA, Kim D, Baim DS, et al. Coronary-subclavian steal: An unusual cause of angina pectoris after successful internal mammary-coronary artery bypass grafting. Cathet Cardiovasc Diagn 1991;24:274–276. 2. Olsen CO, Dunton RF, Maggs PR, Lahey SJ. Review of coronary-subclavian steal following internal mammary artery-coronary artery bypass surgery. Ann Thorac Surg 1988;46:675–678. 3. Tyras DH, Barner HB. Coronary-subclavian steal. Arch Surg 1977;112:1125–1127. 4. A new vascular syndrome: “The subclavian steal” (editorial). N Engl J Med 1961;265:912. 5. Granke K, Van Meter CH Jr., White CJ, et al. Myocardial ischemia caused by postoperative malfunction of an internal mammary coronary artery graft. J Vasc Surg 1990;11:659–664. 6. Mehigan JT, Buch WS, Pipkin RD, Fogarty TJ. Subclavian-carotid transposition for the subclavian steal syndrome. Am J Surg 1978;136:15–20. 7. Myers WO, Lawton BR, Ray JF, et al. Axilloaxillary bypass for subclavian steal syndrome. Arch Surg 1979;114:394–399. 8. Weimann S, Willeit H, Flora G. Direct subclavian-carotid anastomosis for the subclavian steal syndrome. Eur J Vasc Surg 1987;1:305–310. 9. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999;33:1238–1245. 10. Burke DR, Gordon RL, Mishkin JD, et al. Percutaneous transluminal angioplasty of subclavian arteries. Radiology 1987;164:699–704. 11. Insall RL, Lambert D, Chamberlain J, et al. Percutaneous transluminal angioplasty of the innominate, subclavian and axillary arteries. Eur J Vasc Surg 1990;4:591–595. 12. Takach TJ, Reul GJ, Gregoric I, et al. Concomitant subclavian and coronary artery disease. Ann Thorac Surg 2001;71:187–189. 13. Chang JB. Current state of extra-anatomic bypasses. Am J Surg 1986;152:202–205. 14. Singh RN. Atherosclerosis and the internal mammary arteries. Cardiovasc Intervent Radiol 1983;6:72–77. 15. Wilms G, Baert A, Dewaele D, et al. Percutaneous transluminal angioplasty of the subclavian artery: Early and late results. Cardiovasc Intervent Radiol 1987;10:123–128. 16. Mathias KD, Luth I, Haarmann P. Percutaneous transluminal angioplasty of proximal subclavian artery occlusions. Cardiovasc Intervent Radiol 1993;16:214–218. 17. Levitt RG, Wholey MH, Jarmolowski CR. Subclavian artery angioplasty for treatment of coronary artery steal syndrome. J Vasc Interv Radiol 1992;3:73–76. 18. Eggebrecht H, Naber CK, Oldenburg O, et al. Percutaneous transluminal laser guide wire recanalization of chronic subclavian artery occlusion in symptomatic coronary-subclavian steal syndrome. Cathet Cardiovasc Interv 2000;51:500–504. 19. Vitek JJ, Kieler FS. Brachiocephalic artery dilatation by percutaneous transluminal angioplasty. Radiology 1986;158:779–785. 20. Ringlestein EB, Zeumer H. Delayed reversal of vertebral artery flow following percutaneous transluminal angioplasty for subclavian steal syndrome. Neuroradiology 1984;26:189–198.