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Ann Thorac Surg 2002;74:1293-1294
© 2002 The Society of Thoracic Surgeons

Correspondence

Subclavian artery stenosis impairs flow in left internal mammary artery grafts

Simon Fortier, MDa, Roland G. Demaria, MDa, Louis P. Perrault, MD, PhDa

a Department of Surgery and Research Center, Montreal Heart Institute, 5000 Belanger St E, Montreal, PQ H1T 1C8, Canada

e-mail: lpperrau{at}icm.umontreal.ca

To the Editor

We read with great inte rest the article by Hennen and colleagues [1] about subclavian artery (SCA) stenosis and its effects on internal mammary artery (IMA) flow. The authors reported the cases of 2 patients with stenosis of the left SCA impairing left IMA grafts who were studied using the flow-wire technique after coronary artery bypass grafting (CABG). Emphasizing the superiority and the importance of arterial conduits such as the IMA for CABG, Hennen and associates demonstrated the usefulness of this technique for evaluation of the hemodynamic extent of SCA stenosis.

We [2] reported our experience with SCA stenosis in 1993. Eleven patients underwent percutaneous transluminal angioplasty (PTA) from 1987 to 1992 at the Montreal Heart Institute. The stenosis was diagnosed before CABG in 4 patients and after CABG in 7 patients. The mean interval between operation and postoperative diagnosis of SCA stenosis was 26 months (range, 2 to 38 months). After treatment with PTA, evaluation was performed with Doppler ultrasonography and angiography. Nine of the 11 patients had no further angina at follow-up (meantime, 38 ± 17 months), and 2 patients (1 in each group) had exercise-induced mild angina. No evidence of restenosis was found in any patient during follow-up Doppler studies. A more recent review of our experience from 1995 to 2001 showed a patency rate of 85% in 13 patients with follow-up ranging from 6 months to 4 years (unpublished data). Stents were used in only 2 patients.

Hennen and colleagues recommend preoperative Doppler ultrasonography to exclude stenosis of the proximal SCA when use of the IMA is planned in CABG. However, the incidence of this stenosis is rare, and we believe that history and physical examination should suffice as the initial investigation. Patients with arm claudication history, upper limb ischemia, symptoms of cerebral or vertebrobasilar insufficiency, a significant difference in arm pressures, or a supraclavicular murmur should be further examined with Doppler ultrasonography, followed by angiography for major stenosis.

In the case of postoperative recurrence of angina, looking for proximal stenosis of the SCA is essential. As mentioned by Hennen and co-workers, the treatment of choice is PTA. The role of preoperative angioplasty before use of an in situ IMA graft remains controversial, but with the clinical results we have reported and the good long-term results obtained with PTA of the SCA with or without a stent (which carries a 20% and 10% restenosis rate, respectively) [3], this approach is justified.

References

  1. Hennen B., Markwirth T., Scheller B., Schäfers H.-J., Wendler O. Impaired flow in left internal mammary artery grafts due to subclavian artery stenosis. Ann Thorac Surg 2001;72:917-919.[Abstract/Free Full Text]
  2. Perrault L.P., Carrier M., Hudon G., Lemarbre L., Hébert Y., Pelletier L.C. Transluminal angioplasty of the subclavian artery in patients with internal mammary grafts. Ann Thorac Surg 1993;56:927-930.[Abstract]
  3. Henry M., Amor M., Henry I., Ethevenot G., Tzvetanov K., Chati Z. Percutaneous transluminal angioplasty of the subclavian arteries. J Endovasc Surg 1999;6:33-41.[Medline]




This Article
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