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Ann Thorac Surg 1995;60:1810-1812
© 1995 The Society of Thoracic Surgeons

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Case report

Coronary Subclavian Steal: A Recurrent Case With Notes on Detecting the Threat Potential

National Defence Medical Centre and University of Ottawa Heart Institute, Ottawa, Ontario, Canada

Accepted for publication June 17, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
A 43-year-old military patient with silent myocardial ischemia due to proximal anterior descending coronary artery and major diagonal branch stenoses had left and right internal mammary artery grafts in 1973, with excellent angiographic results. In 1984, silent ischemia recurred, due to proximal subclavian occlusion with collateral subclavian steal from the left internal mammary artery. A carotid--subclavian artery graft required replacement in 1987 and in 1989 for steal recurrence from graft stenosis due to thrombosis/atherosclerosis. The final 12-mm graft remained smooth with conventional anticoagulant therapy. However, in 1994, ostial compromise of the left internal mammary artery reduced flow enough to require relief of the original and unchanged anterior descending stenosis by transluminal angioplasty and stent placement. Observations are made on subclavian steal and simple methods for detecting its potential for occurrence.

	Introduction

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``The complex hemodynamic situation created by uniting the fate of the arm and the myocardium makes scrupulous evaluation essential.'' A. Hedley Brown [1]

In 1961, Reivich and associates [2] described cerebral ischemia due to flow reversal in a vertebral artery arising beyond subclavian stenosis. An editorial [3] felicitously named this ``the subclavian steal.'' Collateral inflow from other subclavian branches was predictable, but not clinically significant until the internal mammary (internal thoracic) arteries (IMAs) were used as coronary bypass grafts from the early 1970s. In 1974, Harjola and Valle [4] reported ``delay in the flow'' of contrast medium in an IMA beyond subclavian stenosis, which they corrected by carotid--subclavian artery grafting. In 1977, however, Brown [1] reported true coronary subclavian steal in a patient who died at the end of a coronary bypass procedure using both IMAs; retrograde coronary to subclavian flow was measured by flowmeter at 100 mL/min but incorrectly ascribed to probe reversal. Brown believed that this patient died because coronary subclavian steal was not overcome by inflow through native channels and the other grafts, found patent at autopsy. Other examples of coronary subclavian steal have been described; in 1977, Tyras and Barner [5] reported 2 cases (0.44%) in 450 patients having IMA--coronary artery grafting. Angina may result but, as in our case of recurring coronary steal, the iatrogenic myocardial perfusion deficit may be silent. Stenosis of the brachiocephalic trunk, producing ``innominate grand larceny,'' requires transthoracic endarterectomy; this is not usually done for subclavian obstruction, which is most commonly treated by carotid--subclavian artery grafting, preferably with a synthetic conduit. Percutaneous transluminal subclavian angioplasty has been described [6], and more recently [7], directional atherectomy.

A 43-year-old Royal Canadian Air Force Navigator, whose legs were badly burned in a 1957 aircraft accident, was referred for new electrocardiographic abnormalities, having no cardiac discomfort then, nor at any time since. Arm blood pressures (BPs) were equal. Treadmill exercise test (TMT) produced ventricular tachycardia and electrocardiographic ischemia. Left ventriculogram was normal. Important proximal stenoses in the anterior descending coronary artery (ADCA) and in its major diagonal branch, other coronary vessels being unremarkable, made us consider coronary bypass, despite lack of symptoms [8]. Because burn scars would preclude saphenous vein use, coronary angiography included selective demonstration of large IMAs; there were no subclavian pressure gradients.

In 1973, the right IMA (RIMA) was grafted to the diagonal branch and the left IMA (LIMA) to the ADCA, with excellent angiographic results then and a year later. In 1984, after he had discontinued antiplatelet therapy, the patient's exercise tolerance was diminished and his TMT again was positive. The BP difference between the arms was 60 mm Hg. The ADCA stenosis was unchanged but the diagonal branch was occluded above its graft and there was new nonobstructive disease in other coronary vessels; the RIMA was excellent but contrast medium coursing down the ADCA flowed rapidly up the LIMA (Fig 1) and into the left subclavian artery, opacifying it beyond the proximal occlusion (Fig 2). Selective right vertebral artery angiography showed a large high-flow vessel, sending equal streams to normal basilar and large left vertebral arteries; LIMA inflow produced turbulent dilution of this retrograde flow into the left subclavian artery (Fig 3). Nonobstructive disease was seen in both common and external carotid arteries. An 8-mm GoreTex (W. L. Gore & Assoc, Flagstaff, AZ) common carotid--subclavian artery graft (CSG) was placed with excellent angiographic results. Arm BPs were the same but a supraclavicular thrill and bruit have been noted since; TMT was negative.

View larger version (147K): [in this window] [in a new window]   Fig 1. . Left lateral view of left coronary angiogram shows contrast medium flowing retrograde from anterior descending to left internal mammary artery (arrow).

View larger version (147K): [in this window] [in a new window]   Fig 2. . Left coronary artery contrast medium injection leads to opacification of left internal mammary artery and left subclavian artery (arrow). Tongue of contrast medium above subclavian is in a terminal subclavian cervical branch.

View larger version (147K): [in this window] [in a new window]   Fig 3. . Contrast medium injected into right vertebral artery flows retrograde in left vertebral artery and opacifies proximal left subclavian artery. Note distortion of subclavian contrast medium column by inflow from left internal mammary artery (arrow).

At reoperation, organized clot and fresh distal thrombus had produced a slit lumen. A new 8-mm Gore-Tex graft was placed, and no postoperative angiography was performed.

In 1989, worsening claudication led to aorta--bifemoral grafting. Interarm BP difference was 30 mm Hg; the TMT again was positive. The ADCA was unchanged but other coronary stenoses increased to about 25%. The RIMA was clean with high flow, but there was no LIMA flow either way at rest. The CSG was irregular with 20% proximal and 50% distal stenoses. The left vertebral artery flow was sluggish antegrade, and there was increasing carotid disease. After much discussion, we replaced the GoreTex at a second reoperation with a 12-mm Hemashield CSG graft (Meadox Medicals, Oakland, NJ); thrombus/atherosclerosis had reduced the lumen to less than 50%. No postoperative angiogram was performed. Long-term warfarin anticoagulant therapy was started and aspirin administration continued.

In 1992, the patient was asymptomatic and the arm BPs were the same, but the TMT was positive. There was increasing ADCA calcification, but the stenosis was unchanged. The CSG was smooth but there was 80% narrowing of the proximal left subclavian artery at the anastomosis heel. The LIMA was smaller with low flow, and the RIMA was excellent. No intervention was performed.

In 1994, arm BPs were the same but the TMT was still positive. There was minimal left ventricular anterior hypokinesis and increasing nonobstructive coronary disease, but the ADCA was unchanged. The CSG was regular, but the distal anastomosis heel stenosis was now 90%. Left vertebral artery flow was normal, but LIMA flow was slow, probably because of ostial compromise. To correct critically low ADCA flow, we performed percutaneous transluminal angioplasty and stent placement, which reduced the stenosis of the lumen to 10%: old problem (happily static for two decades)-new solution. The TMT was now negative.

At the 1995 follow-up, the patient was asymptomatic; medical therapy continued. Medicine being no less hazardous than surgery, anticoagulant therapy was complicated by gastrointestinal bleeding of unknown cause (international normalized ratio, 2.4) requiring transfusion of 5 units; there was no recurrence. Arm BPs were equal; there were a supraclavicular thrill and loud bruit as before.

	Comment

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Preoperative aortic arch angiography has been recommended for patients who will have IMA coronary grafting. We think this adds a cumbersome, time-consuming, and expensive procedure to coronary cine-angiography. However, we agree completely with Brown's [1] axiom at the head of this article. Consequently, when angiography in progress indicates the likelihood of coronary bypass, we routinely opacify the IMAs selectively during the same cine study, seeking a pressure gradient while traversing the subclavian vessels and making small hand injections of contrast medium to visualize them. This is done with the versatile Judkin's right coronary catheter, or, in about one third of cases, a specially preformed IMA catheter (Cordis Corp, Miami, FL). The examinations require caution but are not difficult and take little extra time. Since 1969, we have premedicated angiography patients with aspirin and dipyridamole to inhibit platelet aggregation; the only complication of many IMA angiograms has been 1 case of mild, transient internuclear ophthalmoplegia, lasting a few hours. An example of atherosclerotic subclavian stenosis, which resulted in the decision not to use the affected internal mammary artery for coronary bypass, is shown in Figure 4. Coronary subclavian steal is uncommon but sufficiently important to think of before most coronary bypass operations. Angiography is specific and ideal, but clinical assessment takes precedence. Bedside examination of all patients with suspected cardiovascular disease should include BP measurement in both arms and bilateral supraclavicular auscultation.

View larger version (149K): [in this window] [in a new window]   Fig 4. . Left subclavian angiogram shows moderately severe stenosis (arrow) but preserved antegrade flow in left vertebral artery and left internal mammary artery. Patient had subclavian bruit, which disappeared in 4 years when left subclavian artery occluded. The left internal mammary artery was not used for coronary bypass.

	Acknowledgments

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
This work was supported by a grant from the Chief of Research and Development of the Department of National Defence, Canada, which does not, however, necessarily agree with our opinions or conclusions.

We acknowledge, with pleasure, the assistance of Lucie Morin-Brock in preparing the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Address reprint requests to Dr FitzGibbon, Cardio-Pulmonary Unit, National Defence Medical Centre, 1745 Alta Vista Dr, Ottawa, Ont, K1A 0K6, Canada.

	References

Top Footnotes Abstract Introduction Comment Acknowledgments References

 

1. Brown AH. Coronary steal by internal mammary graft with subclavian stenosis. J Thorac Cardiovasc Surg 1977;73:690–3.[Abstract]
2. Reivich M, Holling HE, Roberts B, Toole JF. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med 1961;265:878–85.[Medline]
3. A new vascular syndrome-``the subclavian steal'' [Editorial]. N Engl J Med 1961;265:912–3.
4. Harjola P-T, Valle M. The importance of aortic arch or subclavian angiography before coronary reconstruction. Chest 1974;66:436–8.[Abstract/Free Full Text]
5. Tyras DH, Barner HB. Coronary--subclavian steal. Arch Surg 1977;112:1125–7.[Abstract/Free Full Text]
6. Shapira S, Braun SD, Puram B, Patel G, Rotman H. Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery. J Am Coll Cardiol 1991;18:1120–3.[Abstract]
7. Breall JA, Grossman W, Stillman IE, Gianturco LE, Kim D. Atherectomy of the subclavian artery for patients with symptomatic coronary-subclavian steal syndrome. J Am Coll Cardiol 1993;21:1564–7.[Abstract]
8. FitzGibbon GM, Keon WJ, Burton JR. Aorta--coronary bypass in patients with coronary artery disease who do not have angina. J Thorac Cardiovasc Surg 1984;87:717–24.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wilbert J. Keon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by FitzGibbon, G. M. Articles by Keon, W. J. Search for Related Content PubMed PubMed Citation Articles by FitzGibbon, G. M. Articles by Keon, W. J.