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Ann Thorac Surg 1997;63:853-854
© 1997 The Society of Thoracic Surgeons

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Case Reports

Concomitant Cerebral and Coronary Subclavian Steal

Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas

Accepted for publication October 24, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report the unusual presentation of simultaneous coronary and cerebrovascular insufficiency secondary to subclavian steal in a patient previously treated with coronary artery bypass grafting. Movement of the arm produced reversal of flow ("steal") in both the left vertebral and left internal thoracic arteries and resulted in the onset of angina and neurologic symptoms.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Symptomatic occlusive disease of the great vessels occurs infrequently. We report a case involving a patient with both symptomatic occlusive disease of the great vessels and coronary artery disease (CAD) in whom concomitant cerebral and coronary subclavian steal developed. The reversal of flow in the vertebral artery and in a previously placed bypass graft (left internal thoracic artery [ITA] to left anterior descending coronary artery [LAD]) caused coronary and cerebrovascular insufficiency in the patient.

A 54-year-old man with previously documented CAD, peripheral vascular occlusive disease, and Hodgkin's disease presented with symptoms including intermittent bilateral upper-extremity paresthesia and paresis, occasional slurred speech, and intermittent chest pain. The patient reported that symptoms occurred more often with exercise, especially upon movement of the left arm. The Hodgkin's disease had been treated successfully 8 years before admission with upper-body irradiation. The CAD had required coronary artery bypass grafting 7 years before the current admission. At that time, two bypass grafts were made, including one from the left ITA to the LAD.

At the current admission, auscultation demonstrated a bruit in the left supraclavicular fossa with no evidence of bruits over the carotid vessels. A carotid pulse could not be palpated. Systolic blood pressure was diminished in both upper extremities (left arm, 65 mm Hg; right arm, 60 mm Hg; leg, 140 mm Hg). Findings on neurologic examination were nonfocal.

Cineangiography demonstrated multivessel CAD including mid–right coronary artery and proximal obtuse marginal occlusions, with distal reconstitution and a proximal LAD stenosis. A previous saphenous vein bypass graft to the right coronary artery was occluded. The left ITA to LAD bypass graft was patent. However, a 40% stenosis of the proximal left ITA was present.

Arch aortography demonstrated occlusion of the innominate and bilateral common carotid arteries, preocclusive stenosis of the right subclavian artery, a 50% stenosis of the proximal left subclavian artery, and severe (70% stenosis) bilateral carotid bifurcation disease (Fig 1). Collateral flow originating from the left vertebral artery supplied the circulation in the anterior cerebrum and the right arm (Fig 2). When the left arm was exercised during angiography, blood flow was reversed in the left vertebral artery and the left ITA, and symptoms recurred.

View larger version (43K): [in this window] [in a new window]   Fig 1. . Preoperative and postoperative findings. Solid arrows = primary and collateral blood flow; dashed arrows = reversal of flow ("steal") occurring during left arm exercise.

View larger version (58K): [in this window] [in a new window]   Fig 2. . (A) Arch aortography (preoperative) demonstrating solitary cerebrovascular blood flow through the left vertebral artery. (B) Late angiogram (preoperative) demonstrating delayed retrograde filling of the right vertebral and right carotid arteries ( arrows) by collaterals.

	Comment

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Although symptomatic brachiocephalic disease occurs infrequently, 45% of all such patients have concomitant CAD [1, 2]. The presence of angina and cerebrovascular symptoms in this patient was clearly related to brachiocephalic disease and was reproduced during angiography with arm exercise. At that time, simultaneous reversal of flow in both the ITA and vertebral artery was demonstrated.

The severity of this patient's occlusive disease at a relatively young age suggests a concomitant effect of atherosclerosis and irradiation. The pattern of disease progression in this patient is typical of radiation-associated pathologic patterns: a delayed onset of occlusive disease that occurs within 10 years of exposure [3].

The existence of isolated coronary subclavian steal has been documented by others [4–8]. Successful correction with relief of symptoms has been accomplished by carotid–subclavian bypass [6], angioplasty [7], or atherectomy [8] of the subclavian artery. Late recurrence has been documented in 1 patient, who had thrombosis of an initially successful carotid subclavian bypass [6]. Direct transthoracic revascularization of the subclavian artery (as in this patient) allows use of the aorta for proximal inflow and imparts a theoretic advantage for long-term patency [2]. The unusual presence of proximal left ITA stenosis in a patient exposed to radiation prompted a separate aorta-to-LAD bypass graft with saphenous vein.

The combination of coronary and cerebrovascular insufficiency is suggestive of concomitant CAD and occlusive disease of the great vessels and mandates a full clinical and radiologic evaluation. The immediate outcome in this patient suggests that simultaneous revascularization of the coronary arteries and great vessels can be performed successfully, resulting in a symptom-free outcome.

	Footnotes

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Address reprint requests to Dr Reul, Cardiovascular Surgery, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.

	References

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1. Evans WE, Williams TE, Hayes JP. Aortobrachiocephalic reconstruction. Am J Surg 1988;156:100–2.[Medline]
2. Takach TJ, Reul GJ. Total aortic arch reconstruction for multiple great vessel occlusive disease. Semin Vasc Surg 1996;9:118–24.[Medline]
3. Butler MS, Lane RHS, Webster JHH. Irradiation injury to large arteries. Br J Surg 1980;67:341–3.[Medline]
4. Brown AH. Coronary steal by internal mammary graft with subclavian stenosis. J Thorac Cardiovasc Surg 1977;73:690–3.[Abstract]
5. Tyras DH, Barner HB. Coronary-subclavian steal. Arch Surg 1977;112:1125–7.[Abstract/Free Full Text]
6. FitzGibbon GM, Keon WJ. Coronary subclavian steal: a recurrent case with notes on detecting the threat potential. Ann Thorac Surg 1995;60:1810–2.[Abstract/Free Full Text]
7. Shapira S, Braun SD, Puran 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]
8. 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]

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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): Thomas J. Takach Martin L. Beggs Verlyn J. Nykamp George J. Reul, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takach, T. J. Articles by Reul, G. J. Search for Related Content PubMed PubMed Citation Articles by Takach, T. J. Articles by Reul, G. J., Jr