Coronary Subclavian Steal Syndrome and Acute Anterior Myocardial Infarction

Abstract

C oronary subclavian steal syndrome (CSSS) is an uncommon complication after coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA). 1-3 CSSS results from the retrograde blood flow through the LIMA graft in the left subclavian artery (SCA), consecutive to a proximal SCA stenosis or total occlusion. CSSS usually manifests as stable angina pectoris 1 but also rarely presents as ST-segment-elevation myocardial infarc-tion secondary to an acute SCA occlusion or plaque rupture. 1,2 Anterior ST-segment-elevation myocardial infarction resulting from an acute thrombotic occlusion of the left anterior descending (LAD) artery at the LIMA-to-LAD anastomotic site in a patient with concomitant CSSS may be a challenging problem during primary percutaneous coronary intervention and has not been reported to date. Here, we report on a 62-year-old woman with hypertension, dyslipidemia, and peripheral artery disease who underwent CABG surgery using a LIMA graft to the LAD 12 years earlier (Figure 1 and Movie I in the online-only Data Supplement). The patient presented to the emergency department with de novo exertional chest pain. The 12-lead ECG showed negative T waves in the anterior leads, and her cardiac biomarkers were normal. During admission, the patient developed chest pain at rest associated with paresthesias of the left hand. An ECG showed new anterior ST-segment elevation, and the patient was transferred for primary percutaneous coronary intervention. The left coronary angiogram (Movie II in the online-only Data Supplement) showed a patent LAD with critical stenosis at the site of the LIMA-to-LAD anastomosis (Figure 1) and an unexpected retrograde flow through the patent LIMA graft to the left SCA (Figure 1). Interestingly, no angiographically significant stenosis was visualized on the proximal native LAD. An angiogram of the aortic root revealed total occlusion at the origin of the left SCA (Figure 1 and Movie III in the online-only Data Supplement), which, combined with the retrograde flow through the LIMA, confirmed the presence of CSSS with vascularization of the left upper limb depending on the reversed flow through the LIMA graft. Primary percutaneous coronary intervention to the LAD was performed with a drug-eluting stent across the LIMA-to-LAD anastomotic site. The final coronary angiogram (Movie IV in the online-only Data Supplement) demonstrated a restored anterograde flow from the proximal to the distal LAD and a preserved retrograde flow through the LIMA graft to the left SCA (Figure 1). Physical examination revealed a weaker left radial pulse, but plethys-mography confirmed a biphasic pulse wave at the level of the left upper limb. An urgent Doppler ultrasonography showed occlusion of the left SCA and CSSS with reversed flow in the LIMA and anterograde flow in the left vertebral artery. No critical left upper-limb ischemia was documented, and conservative management was suggested. Computed tomographic angiography demonstrated a 15-mm total occlusion at the origin of the le...

Treatment of an Unusual Occurrence of a Complex Left Subclavian Artery/Left Internal Mammary Artery Bifurcation Stenosis in the Setting of Coronary Subclavian Steal Syndrome and Ischemic Left Ventricular Systolic Dysfunction

“…Proximal left SAS was found to occur in 11.8% of patients with both PAD and coronary artery disease requiring CABG [ 2 , 6 ]. In patients who have undergone CABG with LIMA, the estimated incidence of CSSS is between 0.2% and 6.8% [ 2 , 7 ]. Based on data from 98 case reports, the most common manifestation of CSSS is stable/unstable angina (88.6%), MI (11.4%), and CHF or worsening LV systolic dysfunction (13.2%) [ 8 ].…”

Unexpected Stealing From the Heart

“…The incidence of CSSS is about 0.2% to 0.68% of patients referred for CABG surgery with LIMA, but its prevalence is rising as a result of the increased use of LIMA for CABG procedures. Other studies report an incidence of 0.44% as compared to that of subclavian steal syndrome at 5.23% [ 2 , 3 ]. Less frequent causes of left subclavian stenosis include Takayasu, giant cell, and radiation-induced arteritis.…”

“…Less frequent causes of left subclavian stenosis include Takayasu, giant cell, and radiation-induced arteritis. There is also a documented case secondary to an arteriovenous hemodialysis fistula in the left arm [ 2 ].…”

“…Diagnosis of CSSS is supported by noninvasive imaging modalities, such as echo-color Doppler sonography, computed tomographic angiography, and cardiac magnetic resonance angiography of the aortic arch or left subclavian artery. This is done prior to primary percutaneous coronary intervention to avoid potential diagnostic pitfalls [ 2 , 3 ].…”

Coronary subclavian steal syndrome—is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?

“…Coronary subclavian steal syndrome (CSSS) is an uncommon complication following cardiac bypass surgery involving the left internal mammary artery (LIMA) [ 1 ]. Subclavian artery stenosis (SAS) proximal to the LIMA graft can result in retrograde blood flow and diminished myocardial perfusion.…”