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Ann Thorac Surg 2001;71:187-189
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Concomitant subclavian and coronary artery disease

^a Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
^b Department of Cardiology, Texas Heart Institute, Houston, Texas, USA

Accepted for publication August 24, 2000.

Address reprint requests to Dr Cooley, Texas Heart Institute, PO Box 20345, MC 3-258, Houston, TX 77225-0345

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia.

Methods. We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal.

Results. All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years).

Conclusions. Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Excellent long-term patency has been achieved with the internal mammary artery (IMA) as a conduit for revascularization of coronary arteries [1]. However, the presence of concomitant proximal subclavian artery occlusive disease may result in reversal of IMA flow (coronary-subclavian steal; Fig 1) and produce myocardial ischemia [2, 3]. The optimal management of patients with concomitant subclavian and coronary artery disease and the treatment of patients with coronary-subclavian steal have not been established. We reviewed our experience with treatment of such lesions to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal.

View larger version (25K): [in this window] [in a new window]   Fig 1. Reversal of internal mammary artery flow (arrows) with left upper extremity activity (coronary-subclavian steal).(LIMA = left internal mammary artery.)

	Material and methods

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Associated cardiovascular risk factors included hypertension (15 patients, 75.0%), diabetes mellitus (4 patients, 20.0%), and tobacco use (11 patients, 55.0%). All patients with coronary-subclavian steal in this series were symptomatic (angina grades 2 or 3) on admission. In patients with stable angina, myocardial perfusion was evaluated, and the presence of ischemia was documented with exercise electrocardiography, stress thallium uptake, or dipyridamole infusion scan.

Associated vertebrobasilar insufficiency (8 patients, 40.0%) and upper extremity ischemic symptoms (4 patients, 20.0%) were present in 12 patients. Symptoms of ischemia in the upper extremities as well as hemodynamic changes were reproduced in patients with a stable cardiac status by using the method described by Grosveld and colleagues [4]. Ultrasonic duplex scanning with hemodynamic measurements before and after exercise differentiated hemodynamically significant from nonsignificant lesions.

All patients underwent full invasive radiologic evaluation (including arch aortography with runoff views of the carotid, subclavian, and vertebral circulations) and cineangiography of the coronary vessels. Vessel stenosis was determined angiographically by the formula . Significant stenosis in the brachiocephalic vascular distribution was defined as an 80% narrowing of the vessel lumen. All 20 patients in this study had significant left subclavian artery occlusive disease and coronary artery disease that was treated with left IMA to left anterior descending coronary artery bypass. Additional procedures used to treat individual patients were determined by the operative risk and anatomic distribution of disease. Patients in group 1 underwent a median sternotomy for coronary revascularization and simultaneous direct reconstruction of the subclavian artery. Patients in group 2, who experienced symptoms after a previous CABG, had either percutaneous transluminal angioplasty (PTA) and stenting (10 patients, 66.7%) or extrathoracic (carotid-subclavian) bypass (5 patients, 33.3%; Fig 2). The details of our operative [5, 6] and interventional [7, 8] techniques have been described previously. After the initial postoperative visit, patency was assessed at 6-month intervals using ultrasonic duplex scanning, with hemodynamic measurements before and after exercise.

View larger version (19K): [in this window] [in a new window]   Fig 2. Revascularization of the subclavian artery using extrathoracic (carotid-subclavian) bypass.

	Results

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	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The presence of concomitant symptomatic or asymptomatic subclavian artery occlusive disease in patients who present with coronary artery disease requires the surgeon to decide whether to use the IMA as a bypass conduit. Although the use of alternative conduits (such as an IMA free graft, a vein, or the radial artery) will avoid the potential risk for development of coronary-subclavian steal and myocardial ischemia, it is not clear whether other conduits can achieve the documented long-term patency of the standard IMA conduit [1]. The results of our study in a limited number of patients demonstrate that direct revascularization of the subclavian artery by bypass confers protection from development of coronary-subclavian steal in patients who undergo simultaneous CABG using the IMA.

The optimal approach and technique for direct subclavian artery reconstruction has not been established. Recent studies using transthoracic direct revascularization (aorta to subclavian artery or brachial artery bypass) have reported excellent operative and long-term patency [6, 9]. These results have been attributed to maintaining inflow from the aorta rather than from potentially diseased brachiocephalic vessels. Series using short extrathoracic (carotid-subclavian) bypasses have also reported acceptable long-term patency [10]. These good results have been attributed to avoiding the use of long grafts and to originating inflow from nondiseased vessels. We have achieved excellent patency in our series using either transthoracic direct revascularization or short extrathoracic bypass.

In some cases, after CABG with IMA bypass, a patient may develop recurrent myocardial ischemia caused by coronary-subclavian steal, but the syndrome is uncommon. An early report documented an incidence of 0.44% in patients who had received an IMA conduit during CABG [3]. However, the incidence of coronary-subclavian steal at our institution is less than 0.07%, and excluding this report, fewer than 130 cases have been reported in the literature. The steal may result from unrecognized preexisting subclavian artery disease or the progression of arteriosclerosis in that vessel [11–13]. In this series, an analysis of patients initially treated at our institution demonstrated that the cause of coronary-subclavian steal was unappreciated subclavian artery disease in 1 patient and progression of subclavian disease in the remaining patients.

In the 1 patient in whom preexisting subclavian artery stenosis was unappreciated, an upper-extremity blood pressure discrepancy between the two limbs was not documented. Bilateral upper-extremity blood pressure measurements are an excellent screening tool for detecting the presence of subclavian artery stenosis. A blood pressure difference of more than 20 mm Hg is highly suggestive of subclavian artery stenosis [14]. However, the absence of a difference in extremity blood pressure does not exclude the presence of subclavian artery stenosis, because of the frequent occurrence of innominate, bilateral subclavian, and diffuse atherosclerotic occlusive disease in these patients [15]. When screening for subclavian artery stenosis, we have found ultrasonic duplex scanning with hemodynamic measurements before and after exercise to be more reliable than assessment for discrepancy in upper-extremity blood pressure. This method is also effective for documenting patency after an interventional procedure.

The appropriate interventional technique for patients with coronary-subclavian steal should be tailored to individual operative risk and the anatomic distribution of disease. The increased operative risk associated with repeat median sternotomy favors the use either of PTA and stenting or extrathoracic bypass of the subclavian artery rather than a transthoracic approach for direct reconstruction. Although either PTA and stenting or extrathoracic bypass is favored over a repeat median sternotomy, differences exist in operative risk and potential outcome for each technique.

At our institution, PTA and stenting of the subclavian artery is generally performed on an outpatient basis and does not require general anesthesia. An extrathoracic (carotid-subclavian) bypass is currently performed with general anesthesia and, in most cases, requires an overnight hospital stay. Series reporting results of subclavian vessel reconstruction document a better intermediate-term patency after bypass than after PTA and stenting. Cumulative patency rates after subclavian artery angioplasty and stenting were reported to be 81% at 15 months by Martinez and associates [8] and 85.5% at 14 months by Pathan and colleagues [7]. Data from studies evaluating long-term patency after PTA and stenting are currently being evaluated. In contrast, Perler and Williams [10] report a 92% actuarial patency at 5 years after carotid-subclavian bypass. Therefore, patients who undergo PTA and stenting avoid exposure to general anesthesia, require a shorter hospital stay, and have less financial cost. These benefits, however, are attained at the cost of potentially decreased long-term patency. We are continuing to evaluate the long-term outcomes of each approach.

At the present time, our choice of operative or interventional technique is determined by individual patient risk factors and anatomic distribution of disease. Patients with ostial or diffuse atherosclerotic disease are less suited for PTA and stenting. Alternatively, patients who are elderly or who have an overall poor medical condition may be less tolerant of general anesthesia and, therefore, operative bypass. Although the extrathoracic bypass approach is favored at our institution for the operative treatment of proximal subclavian occlusive disease after previous median sternotomy for CABG, others have obtained similar operative success and excellent long-term patency with the use of subclavian artery transposition [16].

We conclude that subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal and its sequelae in the short term. Intermediate-term follow-up indicates that the protection and treatment benefits persist. Continued follow-up will be necessary to determine long-term results.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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 George J. Reul Igor Gregoric J. Michael Duncan James J. Livesay Denton A. Cooley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takach, T. J. Articles by Cooley, D. A. Search for Related Content PubMed PubMed Citation Articles by Takach, T. J. Articles by Cooley, D. A. Related Collections Coronary disease Great vessels