Ann Thorac Surg 2009;88:2036-2038. doi:10.1016/j.athoracsur.2009.05.045
© 2009 The Society of Thoracic Surgeons
Case Reports
Subclavian Artery Thrombosis Associated With Acute ST-Segment Elevation Myocardial Infarction
Cheng-Hsueh Wu, MDa,*,
Shih-Hsien Sung, MDb,e,
Julia Chia-Yu Chang, MDc,
Cheng-Hsiung Huang, MDd,e,
Tse-Min Lu, MDb,e
a Division of Cardiology, Department of Medicine, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
b Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
c Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
d Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
e School of Medicine, National Yang-Ming University, Taipei, Taiwan
Accepted for publication May 14, 2009.
* Address correspondence to Dr Wu, Division of Cardiology, Department of Medicine, Taipei Medical University-Shuang Ho Hospital, No. 291, Zhong-Zheng Rd, Jhonghe City, 235, Taipei, Taiwan (Email: chwu6{at}vghtpe.gov.tw).
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Abstract
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Presentation of acute ST segment elevation myocardial infarction in the setting of acute subclavian artery thrombosis in a patient who underwent coronary artery bypass grafting with a left internal mammary artery graft, which is not believed to have been previously described. We report a 75-year-old woman with presentations of dizziness, nausea, left-arm numbness, and a cold left hand, who later had chest pain develop. Acute ST segment elevation myocardial infarction was diagnosed, and both a computed tomography and an angiography disclosed a thrombus extending from the proximal portion of the left subclavian artery to the orifice of the left internal mammary artery. The patient was free from the previously listed symptoms after undergoing emergent thrombectomy, with complete extraction of the long thrombus from the subclavian artery. Unfortunately, she died of pneumonia and septic shock 11/2 months later.
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Introduction
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Subclavian steal syndrome is a constellation of signs and symptoms that arise from a reversal of vertebral artery blood flow, which causes vertebrobasilar insufficiency and is aggravated by movement of ipsilateral arm due to a proximal subclavian artery stenosis or occlusion. Furthermore, in patients who have received a coronary bypass graft using the left internal mammary artery (LIMA) diverted to the coronary arteries, blood may flow backward away from the heart when there is a critical stenosis at the ipsilateral proximal subclavian artery. This phenomenon is clinically known as the coronary subclavian steal syndrome, and myocardial ischemia may occur in such a setting. As for an acute closure of proximal subclavian artery by thromboembolism, ischemia of upper extremity accompanied with acute ST segment elevation myocardial infarction in a patient with a LIMA graft has not been previously described.
A 75-year-old woman with type 2 diabetes and hypertension underwent coronary artery bypass grafting in 1999. A LIMA graft was anastomosed to the left anterior descending coronary artery, while two vein grafts were anastomosed to the obtuse marginal branch of the left circumflex coronary artery and the right coronary artery. This time, the patient presented to the emergency room with general weakness and dizziness initially. The electrocardiogram revealed a junctional rhythm of 43 beats per minute. Laboratory workup suggested an acute deterioration of renal function with a serum creatinine level of 2.8 mg/dL. Drug-related (verapamil) symptomatic bradycardia was suspected, and a temporary pacemaker was placed.
On day 3 of the patient's hospitalization, her symptoms were left arm numbness, dizziness, and nausea. An attenuation of the left radial pulse and a cold left hand were observed. The next day she complained of chest pain. An electrocardiogram revealed atrial fibrillation and mild ST segment elevation in the precordial leads with reciprocal changes in the lateral leads (Fig 1), suggesting acute anterior wall myocardial infarction. Laboratory workup showed elevated cardiac enzymes, with a creatine kinase level of 514 U/L, creatine kinase MB level of 49 U/L, and a troponin I level of 12.68 ng/mL. An emergent computed tomographic scan disclosed an elongated thrombus at the orifice of the left subclavian artery extending to the axillary region (Figs 2A and 2B). Under the impression of acute ST segment elevation myocardial infarction, an emergent angiography was performed, which disclosed two patent vein grafts. However, a huge thrombus in the proximal left subclavian artery, extending to the orifice of the LIMA, rendered severe obstruction of the left subclavian artery and compromised the LIMA blood flow (Fig 2C). An echocardiogram showed no intracardiac thrombus, but hypokinesis over the anterior wall of the left ventricle with moderate mitral regurgitation was found. Atrial fibrillation related thromboembolism was excluded.
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Fig 2. (A) Computed tomographic chest scan discloses filling defects in the left subclavian artery (arrow). (B) The three-dimensional reconstructed image showed interruption of the left subclavian artery (arrow). (C) Angiography shows a large thrombus (arrowhead) extending from the proximal left subclavian artery to the orifice of the vertebral artery and left internal mammary artery.
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Due to the large size of the thrombus in the subclavian artery, a cardiovascular surgeon was immediately consulted. The patient underwent emergent thrombectomy with complete extraction of the long thrombus (Fig 3) through a left brachial approach by using a Fogarty catheter rather than thrombolysis or open thrombectomy due to poor physical performance. The thrombectomy procedure did not cause any complications while relieving the patient from the previously mentioned symptoms. Her laboratory workup showed negative screenings for lupus anticoagulants, autoimmune antibody, and anti-cardiolipin antibody, normal protein C and S levels, normal tumor makers, but low antithrombin III activity (71% of control, compared with a normal range of 80% to 120%). Acquired antithrombin III deficiency was suspected by a hematologist who suggested the treatment of anticoagulant with warfarin accompanied with dual anti-platelet (aspirin and clopidogrel) therapy. Unfortunately, she had another episode of thrombosis develop at the left popliteal artery with acute limb ischemia of the left leg 2 weeks later. She subsequently underwent another surgical thrombectomy through a left femoral approach by using a Fogarty catheter. During the post-operational period, she contracted nosocomial pneumonia with a poor response to antibiotic treatment, and she finally died of septic shock 11/2 months later.
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Comment
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Coronary subclavian steal syndrome is rare in patients who have received coronary artery bypass grafting. This is caused by a retrograde blood flow through the LIMA to the vertebral and subclavian arteries, resulting from a stenosis over the proximal subclavian artery [1]. The prevalence of subclavian artery stenosis in patients having undergone coronary artery bypass grafting is approximately 0.5% to 1.1% [2, 3]. Typical manifestations include cardiac symptoms of angina and noncardiac symptoms of lightheadedness, left-arm numbness, or weakness. Only a few cases have been reported associating with myocardial infarction. All of those were non-ST segment elevation myocardial infarction [4–7]. Atherosclerotic disease is the most common cause predisposing patients to subclavian artery stenosis. Therefore, preoperative evaluation of the subclavian artery by proximal aortic arch arteriography in patients prior to receiving LIMA grafting is important. However, subclavian artery thrombosis, either acute or subacute, is unable to be predicted before coronary artery bypass grafting. In contrast with coronary artery or graft occlusion, our patient suffered from a simultaneous loss of the left radial pulse and myocardial infarction due to acute thrombosis over the proximal left subclavian artery. Percutaneous transluminal angioplasty in combination with stent implantation is a choice of treatment for symptomatic patients [8]. As for total occlusion of the subclavian artery not amenable by endovascular strategies, surgical intervention is an alternative option.
The cause of the thrombotic subclavian occlusion in our patient remained uncertain. The possible reported causes are the thoracic outlet syndrome [9] induced by chronic extra-arterial compression, radiation therapy [10], mobile thrombosis [11], rheumatic disorder [12], and cardiac origin, such as atrial fibrillation. In our case, antithrombin III deficiency was suspected. However, the mild, low level of antithrombin III observed might not be significant for this episode of thrombosis. This was because thrombosis might directly increase the consumption of antithrombin III. Atrial fibrillation-related thromboembolism should also be considered, even though echocardiography excluded the possibility of intracardiac thrombus. Despite treatment with anticoagulant, another episode of thromboembolism over left popliteal artery occurred. The thrombosis was resolved through a surgical intervention, but the patient died as a result of nosocomial pneumonia and subsequent septic shock.
In summary, we reported the first case in the literature in which a patient, status post-coronary artery bypass grafting with a LIMA graft had an acute ST segment elevation myocardial infarction develop due to acute thrombosis of proximal subclavian artery. Therefore, the subclavian artery disorder should be kept in the differential diagnosis in patients with prior LIMA grafting presenting chest pain.
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References
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- Sullivan KL, Minken SL, White Jr RI. Treatment of a case of thromboembolism resulting from thoracic outlet syndrome with intra-arterial urokinase infusion J Vasc Surg 1988;7:568-571.[Medline]
- Hashmonai M, Elami A, Kuten A, et al. Subclavian artery occlusion after radiotherapy for carcinoma of the breast Cancer 1988;61:2015-2018.[Medline]
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Abstract
Introduction
