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Ann Thorac Surg 1996;62:264-265
© 1996 The Society of Thoracic Surgeons

Case Report

Coronary-Pulmonary Steal Syndrome

Hani K. Najm, MD, Inderjit S. Gill, FRSC(C), Gerald M. FitzGibbon, LRCP&S(Ireland), Wilbert J. Keon, MD

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa Civic Hospital, and Division of Cardiology, National Defence Medical Centre, Ottawa, Ontario, Canada

Accepted for publication January 13, 1996.


   Abstract
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Introduction
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The development of an internal thoracic artery-pulmonary artery fistula after operation is a rare entity of no clear etiology. We report a patient who underwent coronary bypass reoperation, presented 3 years later with angina on exertion, and upon investigation was found to have an internal thoracic artery-pulmonary artery fistula. This patient was managed conservatively.


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With the increasing use of the internal thoracic artery (ITA) as a conduit for coronary artery bypass, we can expect to see a growing number of rare coronary steal syndromes. Tonz and associates [1] in a literature review of steal syndromes after ITA bypass grafting reported 33 cases, of which the most common was coronary-subclavian steal syndrome. None of the cases reported by Tonz and associates included coronary steal secondary to an ITA-pulmonary artery (PA) fistula. We present a case of this rare entity and compare it with 5 other cases reported in the English-language literature.

A 65-year-old male patient underwent coronary bypass reoperation in 1990 with venous diagonal and ITA anterior descending grafts. Three years later, he presented with recurrent angina.

On examination he was found to have a loud continuous murmur similar to that produced by a patent ductus arteriosus along the left sternal border. Selective ITA injection showed a large fistulous communication between the left ITA and branches of the left pulmonary artery, which were fed by this in diastole. There was initial filling of a thumb-sized vascular malformation (Fig 1Go). This patient has since been managed conservatively with adequate control of symptoms.



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  		Fig 1. . Selective angiogram demonstrating left internal thoracic artery (LITA) to left pulmonary artery branch (LPA) fistula (F). Notice the direction of blood flow (arrows).

 

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Currently the use of ITA as a conduit for coronary artery bypass is considered the standard of care, due to its well-documented advantages [2, 3]. An increasing number of cases of ITA coronary steal are being reported in the literature. The most common type is the coronary-subclavian steal syndrome, which is most often due to proximal subclavian artery stenosis resulting in reversal of flow in the ITA. An ITA-PA fistula is very rare. We could find only five reports on ITA-PA fistulas in the English-language literature (Table 1Go).


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  		Table 1. . Reported Cases of Internal Thoracic Artery-Pulmonary Artery Fistula
 
On analyzing the reported cases we find that all patients presented with myocardial ischemia as a result of communication between the ITA and branches of the pulmonary vasculature. We thus propose the term "coronary-pulmonary steal syndrome" (CPSS).

Presentation of CPSS with clinical symptoms in all cases was at least 2 years after operation. There was only 1 case [5] that was discovered at 5 months after operation in a patient who was asymptomatic but had a routine exercise test that was positive. All other cases presented with angina.

Half of the reported cases of CPSS were coronary bypass reoperations [4, 6, current case], which may indicate that it may be related to visceral pleural injury during repeat sternotomy, with subsequent development of a fistula between the raw exposed surface of the lung and the ITA pedicle.

The diagnosis of this pathology requires a high index of suspicion. Patients who present with recurrent angina who have had ITA grafts implanted should undergo selective ITA injection, especially when a new systolic murmur is discovered postoperatively. Other investigations have been reported by Kimmelstiel and associates [6], which include exercise single-photon emission computed tomography, thallium scintigraphy, rest and exercise gated blood pool scanning, and computed tomography.

The management of CPSS is dictated by the presence and the severity of symptoms. The choices are conservative medical management [5–7, current case], surgical division of the fistula [4], or percutaneous coil spring closure [5]. This can potentially cause distal coronary artery embolization and is not recommended. Conservative management with optimal antianginal therapy seems the treatment of choice. In cases of growth of the fistula, poor control of angina, or nuclear scintigraphic evidence of ongoing ischemia, surgical intervention via a left thoracotomy and staple divisions of a small portion of the lung may be the safest method of management [4].

The possible etiology reported in the literature for the development of ITA-PA fistula is that it may result from coagulating but not clipping branches of the ITA. Visceral pleural injury may be an important denominator in the development of this fistula. This may occur from repeat sternotomy or from the mere presence of metal clips in close proximity to the visceral pleura. This local injury may be further aggravated by respiratory movement and the beating heart and eventually may result in a local inflammatory response leading to neovascularization and formation of a tuft of multiple small fistulous communications between the ITA and PA branches. This has been demonstrated in all the reported cases.

Thus CPSS is a rare complication of coronary bypass operations in which an ITA has been used. It is important to recognize this as a possible cause of recurrent angina.


   Acknowledgments
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References
 
We thank Jill Greenwell for assistance in the preparation of the manuscript.


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Address reprint requests to Dr Gill, University of Ottawa Heart Institute, Room H211, 1053 Carling Ave, Ottawa, Ontario, Canada K1Y 4E9.


   References
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 Abstract
 Introduction
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 Acknowledgments
 References
 

  1. Tonz M, von Segesser L, Carrel T, Pasic M, Turina M. Steal syndrome after internal mammary artery bypass grafting-an entity with increasing significance. Thorac Cardiovasc Surg 1993;41:112–7.[Medline]
  2. Lytle BW, Loop FD, Cosgrove DM, Ratliff NB, Easley K, Taylor PC. Long term serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248–58.[Abstract]
  3. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6.[Medline]
  4. Johnson JA, Schmaltz R, Landreneau RJ, et al. Internal mammary artery graft to pulmonary vasculature fistula: a cause of recurrent angina. Ann Thorac Surg 1990;50:297–8.[Abstract/Free Full Text]
  5. Blanche C, Eigler N, Bairey CN. Internal mammary artery to lung parenchyma fistula after aortocoronary bypass grafting. Ann Thorac Surg 1991;52:141–2.[Abstract/Free Full Text]
  6. Kimmelstiel CD, Udelson J, Salem D, et al. Recurrent angina due to a left internal mammary artery-to-pulmonary artery fistula. Am Heart J 1993;125:234–6.[Medline]
  7. Groh WJ, Hovaguimian H, Morton MJ. Bilateral internal mammary to-pulmonary artery fistula after a coronary operation. Ann Thorac Surg 1994;57:1642–3.[Abstract/Free Full Text]



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This Article
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Inderjit S. Gill
Wilbert J. Keon
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