Unstable Angina as a Result of Coronary-Subclavian Steal Syndrome

Abstract

A 75-year-old man was transferred to our department from the local hospital because of recurrent episodes of dyspnea and angina at rest, with significant 3.0-mV STsegment depressions in ECG leads V 3 through V 6 . His medical history was significant for coronary artery disease, 2-vessel coronary artery bypass grafts (1999), nondisabling stroke (2004), type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The patient also complained of dizziness and weakness of the left hand. Clinical examination was characterized by lack of radial pulse, and blood pressure could not be measured on the left arm. The echocardiogram showed apex and inferior wall hypokinesis with slightly diminished ejection fraction (50%).Ultrasound examination revealed occlusion of the left internal carotid artery and reversed flow through the left vertebral artery, confirmed by angiography (Figure 1). Symptomatic vertebral-subclavian steal syndrome was diagnosed.Angiography of the left coronary artery showed the entire left internal mammary artery (LIMA) graft (Figure 2) with reversed flow of contrast into the subclavian artery. The right and circumflex coronary arteries were occluded, as well as the venous graft to the right coronary artery. Contrast injection into the subclavian artery demonstrated critical 90% stenosis in the proximal part of the subclavian artery, with a translesion pressure gradient of 80 mmHg (Figure 3). Contrast selectively injected beyond the lesion merely showed the proximal parts of the left vertebral artery and LIMA, indicating the presence of reversed flow. Direct stenting of the subclavian artery was performed (Figure 4), and anterograde flow through the left vertebral artery and LIMA was reestablished. Control coronary angiography revealed only minor retrograde filling of the distal part of the LIMA, indicating that the subclavian angioplasty had produced favorable results ( Figure 5). At discharge from the hospital, the patient was asymptomatic and the left radial pulse was palpable. Although subclavian steal syndrome is rather rare, it can be manifested as acute coronary syndrome among patients with LIMA grafts or vertebrobasilar insufficiency, especially in the presence of concomitant internal carotid artery occlusion. Percutaneous angioplasty is the preferred treatment option for those patients. DisclosuresNone.

Unexpected Stealing From the Heart

“…Ferrara reported a high incidence restenosis (40.7% over 5 years) in patients who undergo carotid-subclavian bypass [ 4 ]. Percutaneous transluminal angioplasty was the preferred method of treatment for CSSS in a literature review [ 5 ].…”

Coronary-Subclavian Steal: Case Series and Review of the literature

“…Some considerations need to be made regarding the above mentioned cases of “acute coronary syndrome”. Coronary-subclavian steal syndrome is defined as a coronary reversal of flow in the internal mammary artery caused by proximal subclavian artery stenosis, producing myocardial ischemia [ 1 , 2 , 3 ] ( Fig. 4 ).…”

“…However, literature also describes cases of CSSS where enzymatic alterations suggested an acute myocardial infarction, as has been in our case too (case no. 3), even if this scenario is considered rare [ 1 , 2 , 3 , 4 , 5 ]. One possible mechanism involves plaque destabilization in the native coronary or subclavian artery, with distal microembolization from the affected plaque.…”

A Forgotten Vascular Disease with Important Clinical Implications.Subclavian Steal Syndrome: Case Report and Literature Review

“…In such cases, patients may have atypical presentation with weakness of the arm and hand, claudication, cool temperature, and paresthesis [6]. Coronary-Subclavian syndrome is a similar entity that has been described in patients who have undergone CABG with LIMA and a subclavian stenosis reproduce the “steal” syndrome from the coronary arteries via the graft, giving rise to acute coronary symptoms [16–21]. …”

“…Conventional cerebral angiography remains the gold standard, for it has the highest sensibility and specificity; However, this method caries the risks of an invasive procedure [10,23,27–31]. Additionally, in patients with CABG and LIMA, stress test with radiocontrast may be helpful to evaluate for coronary-subclavian syndrome [18–21,32]. …”