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Coronary Subclavian Steal Syndrome Detected During Coronary Bypass Surgery in a Hemodialysis Patient Tomoyuki Minami, M.D.,* Yasuko Uranaka, M.D.,* Makoto Tanaka, M.D.,* Koji Negishi, M.D.,* Keiji Uchida, M.D.,y and Munetaka Masuda, M.D.z *Yokohama Municipal Citizen’s Hospital, Cardiovascular Center, Hodogaya-ku, Yokohama, Kanagawa, Japan; yYokohama City University Medical Center, Cardiovascular Center, Minami-ku, Yokohama, Kanagawa, Japan; and zDepartment of Surgery, Yokohama City University, Kanazawa-ku, Yokohama, Kanagawa, Japan ABSTRACT Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery. doi: 10.1111/jocs.12444 (J Card Surg 2015;30:154–156)
The internal thoracic artery (ITA) is an excellent graft in dialysis patients.1 However, some reports2,3 have shown that the presence of an upper extremity arteriovenous fistula can be a cause of coronary subclavian steal syndrome, mainly due to the ipsilateral subclavian artery stenosis proximal to the origin of the left internal thoracic artery (LITA).4 We experienced a case of a 65-year-old male with coronary subclavian steal syndrome associated with an upper extremity arteriovenous fistula without subclavian artery stenosis. The diagnosis of coronary subclavian steal syndrome was made by transit-time graft flow measurements and fluorescence imaging during the surgery. PATIENT PROFILE Institutional Review Board permission was not necessary to publish this article. A 65-year-old male was admitted with unstable angina. He had end-stage renal disease and has been receiving dialysis for 10 years. Blood access for dialysis
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Tomoyuki Minami, M.D., Yokohama Municipal Citizen’s Hospital, Cardiovascular Surgery, Okazawa-cho 56, Hodogaya-ku, Yokohama, Kanagawa 240-8555, Japan. Fax: þ81-45332-5599; e-mail: [email protected]
was from a left brachiocephalic arteriovenous fistula. Coronary angiography showed a 90% stenosis at the left main trunk and a 99% stenosis at the circumflex branch. LITA angiography demonstrated no stenosis or retrograde flow during the diastolic phase. The preoperative computed tomographic angiography revealed no stenosis at the origin of the left subclavian artery. We performed on-pump coronary revascularization anastomosing the LITA to the left anterior descending artery (LAD) and the saphenous vein graft (SVG) from the ascending aorta to the obtuse marginal branch and the posterolateral branch. During cardiopulmonary bypass, we checked the flow of the LITA graft and SVG by transit-time graft flow measurements. Although weaning from cardiopulmonary bypass was easy, routine intraoperative assessment of the LITA to LAD graft by transit-time graft flow measurements revealed a systolic flow pattern with a high pulsatility index (PI) and almost zero mean flow (Fig. 1). We performed fluorescence imaging, which showed reverse flow from LAD to LITA. Coronary subclavian steal syndrome associated with left upper extremity arteriovenous fistula was suspected and sphygmomanometer cuffs were applied to the left upper extremity to occlude the fistula to confirm our diagnosis. During application of the cuffs, transit-time graft flow measurements demonstrated diastolic flow patterns and a low PI in the LITA graft with improved flow (Fig. 2). We decided to use
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Figure 1. Transit-time graft flow measurements of LITA to LAD after cardiopulmonary bypass revealed unsatisfactory flow; a systolic pattern with a high PI and almost zero mean flow.
Figure 3. Transit-time graft flow measurements after anastomosis of the proximal LITA to the ascending aorta by off-pump technique. A diastolic flow pattern with an acceptable PI and a satisfactory mean flow was obtained.
LITA as a free graft from the ascending aorta to the LAD. After performing the proximal anastomosis using an off-pump technique, a flow study of the free LITA graft revealed a diastolic flow pattern with an acceptable PI and a satisfactory mean flow, and fluorescence imaging showed antegrade flow from the LITA to LAD (Fig. 3). Postoperative coronary angiography demonstrated patency of the LITA to LAD graft.
It is known that a significant left subclavian artery stenosis can potentially induce coronary subclavian steal syndrome in nonhemodialysis patients in whom the LITA is used for coronary revascularization.4 The prevalence of subclavian artery stenosis in hemodialysis patients is considered to be higher than other patients because of an increased incidence of peripheral artery disease in these patients. Therefore, it is important to assess the subclavian artery using imaging modalities, such as computed tomographic angiography or magnetic resonance angiography, particularly in hemodialysis patients who are referred for coronary revascularization. Kato et al. reported that preoperative LITA angiography demonstrated retrograde flow during the diastolic phase in a hemodialysis patient with left upper extremity arteriovenous fistula, and coronary subclavian steal syndrome is considered to be caused by the presence of a high-flow arteriovenous fistula ipsilateral to the ITA.3,6 A high-flow arteriovenous fistula draws flow away from a relatively higher resistance zone such as the coronary artery where the ITA graft is anastomosed to the lower resistance zone such as a vein or to the hemodialysis circuit, particularly during hemodialysis. This can cause symptoms of angina even after successful coronary revascularization. However, Rahbar et al.7 reported no significant changes in the Doppler flow hemodynamics of the ipsilateral or contralateral ITA after manual occlusion of the arteriovenous fistula at rest and during hemodialysis. Therefore, the existence of the coronary subclavian steal syndrome in the absence of subclavian artery stenosis is still debatable. In our case, assessment of the LITA to LAD anastomoses using transit-time graft flow measurements revealed that the flow pattern significantly changed after manual occlusion of the arteriovenous fistula ipsilateral to the ITA. As a result, we were able to diagnose coronary subclavian steal syndrome associated with the high-flow left upper extremity arteriovenous fistula during the surgery. Ligation of the arteriovenous fistula was considered during the surgery, but that strategy was abandoned due to the loss of very
DISCUSSION Two distinct pathophysiological processes may lead to coronary subclavian steal syndrome in hemodialysis patients. First, the presence of a significant stenosis in the proximal part of the subclavian artery can cause a steal phenomenon when the ITA ipsilateral to the arteriovenous fistula is used as a graft for revascularization.5 Second, the presence of a high-shunt flow in the arteriovenous fistula ipsilateral to the ITA leads to coronary subclavian steal syndrome even without subclavian artery stenosis.6
Figure 2. Transit-time graft flow measurements after application of sphygmomanometer cuffs to the left upper extremity to diagnose coronary subclavian steal syndrome associated with left upper extremity arteriovenous fistula. During application of the cuffs, graft flow was improved with a diastolic flow pattern associated with low PI.
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important access for hemodialysis. Consequently, we decided to use LITA as a free graft from the ascending aorta to the LAD. Preoperative ipsilateral ITA and subclavian artery angiography is mandatory in hemodialysis patients receiving coronary revascularization. When ipsilateral subclavian artery stenosis is observed, stenting of the proximal subclavian artery stenosis may be performed in order to utilize ipsilateral ITA for grafting. Alternatively contralateral ITA or free ITA grafts must be utilized. However, preoperative prediction of the occurrence of coronary subclavian steal syndrome due to high flow arteriovenous fistula is still difficult. Therefore, we strongly recommend intraoperative assessment of the ITA graft using transit-time graft flow measurements combined with fluorescence imaging. When an inadequate flow with unacceptable flow pattern is observed in the ITA, additional assessment using fluorescence imaging might be helpful. Intraoperative re-anastomosis should be performed when the possibility of coronary subclavian steal syndrome exists. In addition, in hemodialysis patients who received an ITA graft ipsilateral to the arteriovenous fistula, careful postoperative monitoring for symptoms of angina during dialysis is very important.
J CARD SURG 2015;30:154–156
REFERENCES 1. Ura M, Sakata R, Nakayama Y, et al: The impact of chronic renal failure on atherosclerosis of the internal thoracic arteries. Ann Thorac Surg 2001;71:148–151. 2. Gaudino M, Serricchio M, Luciani N, et al: Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003;107:2653–2655. 3. Kato H, Ikawa S, Hayashi A, et al: Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003;75:270– 271. 4. Carrascal Y, Arroyo J, Fuertes JJ, et al: Massive coronary subclavian steal syndrome. Ann Thorac Surg 2010;90: 1004–1006. 5. Nanda S, Longo S, Pamula J, et al: Recurrent pulmonary edema induced by coronary-subclavian steal syndrome during hemodialysis. Eur J Cardiothorac Surg 2009;35:740– 742. 6. Crowley SD, Butterly DW, Peter RH, et al: Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002;40:852–855. 7. Rahbar R, McGee WR, Birdas TJ, et al: Upper extremity arteriovenous fistulas induce modest hemodynamic effect on the in situ internal thoracic artery. Ann Thorac Surg 2006;81:145–147.
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Coronary Subclavian Steal Syndrome Detected During Coronary Bypass Surgery in a Hemodialysis Patient Tomoyuki Minami, M.D.,* Yasuko Uranaka, M.D.,* Makoto Tanaka, M.D.,* Koji Negishi, M.D.,* Keiji Uchida, M.D.,y and Munetaka Masuda, M.D.z *Yokohama Municipal Citizen’s Hospital, Cardiovascular Center, Hodogaya-ku, Yokohama, Kanagawa, Japan; yYokohama City University Medical Center, Cardiovascular Center, Minami-ku, Yokohama, Kanagawa, Japan; and zDepartment of Surgery, Yokohama City University, Kanazawa-ku, Yokohama, Kanagawa, Japan ABSTRACT Coronary subclavian steal syndrome associated with upper extremity arteriovenous fistula is an uncommon but potentially life-threatening condition. We present a case of a 65-year-old male on hemodialysis with a left upper extremity arteriovenous fistula who underwent coronary revascularization involving bypass with the left internal thoracic artery to the left anterior descending artery. Intraoperative transit-time graft flow measurements and fluorescence imaging showed a reversed flow in the left internal thoracic artery, and the left internal thoracic artery was successfully converted as a free graft from the ascending aorta to the left anterior descending artery. doi: 10.1111/jocs.12444 (J Card Surg 2015;30:154–156)
The internal thoracic artery (ITA) is an excellent graft in dialysis patients.1 However, some reports2,3 have shown that the presence of an upper extremity arteriovenous fistula can be a cause of coronary subclavian steal syndrome, mainly due to the ipsilateral subclavian artery stenosis proximal to the origin of the left internal thoracic artery (LITA).4 We experienced a case of a 65-year-old male with coronary subclavian steal syndrome associated with an upper extremity arteriovenous fistula without subclavian artery stenosis. The diagnosis of coronary subclavian steal syndrome was made by transit-time graft flow measurements and fluorescence imaging during the surgery. PATIENT PROFILE Institutional Review Board permission was not necessary to publish this article. A 65-year-old male was admitted with unstable angina. He had end-stage renal disease and has been receiving dialysis for 10 years. Blood access for dialysis
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Tomoyuki Minami, M.D., Yokohama Municipal Citizen’s Hospital, Cardiovascular Surgery, Okazawa-cho 56, Hodogaya-ku, Yokohama, Kanagawa 240-8555, Japan. Fax: þ81-45332-5599; e-mail: [email protected]
was from a left brachiocephalic arteriovenous fistula. Coronary angiography showed a 90% stenosis at the left main trunk and a 99% stenosis at the circumflex branch. LITA angiography demonstrated no stenosis or retrograde flow during the diastolic phase. The preoperative computed tomographic angiography revealed no stenosis at the origin of the left subclavian artery. We performed on-pump coronary revascularization anastomosing the LITA to the left anterior descending artery (LAD) and the saphenous vein graft (SVG) from the ascending aorta to the obtuse marginal branch and the posterolateral branch. During cardiopulmonary bypass, we checked the flow of the LITA graft and SVG by transit-time graft flow measurements. Although weaning from cardiopulmonary bypass was easy, routine intraoperative assessment of the LITA to LAD graft by transit-time graft flow measurements revealed a systolic flow pattern with a high pulsatility index (PI) and almost zero mean flow (Fig. 1). We performed fluorescence imaging, which showed reverse flow from LAD to LITA. Coronary subclavian steal syndrome associated with left upper extremity arteriovenous fistula was suspected and sphygmomanometer cuffs were applied to the left upper extremity to occlude the fistula to confirm our diagnosis. During application of the cuffs, transit-time graft flow measurements demonstrated diastolic flow patterns and a low PI in the LITA graft with improved flow (Fig. 2). We decided to use
J CARD SURG 2015;30:154–156
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Figure 1. Transit-time graft flow measurements of LITA to LAD after cardiopulmonary bypass revealed unsatisfactory flow; a systolic pattern with a high PI and almost zero mean flow.
Figure 3. Transit-time graft flow measurements after anastomosis of the proximal LITA to the ascending aorta by off-pump technique. A diastolic flow pattern with an acceptable PI and a satisfactory mean flow was obtained.
LITA as a free graft from the ascending aorta to the LAD. After performing the proximal anastomosis using an off-pump technique, a flow study of the free LITA graft revealed a diastolic flow pattern with an acceptable PI and a satisfactory mean flow, and fluorescence imaging showed antegrade flow from the LITA to LAD (Fig. 3). Postoperative coronary angiography demonstrated patency of the LITA to LAD graft.
It is known that a significant left subclavian artery stenosis can potentially induce coronary subclavian steal syndrome in nonhemodialysis patients in whom the LITA is used for coronary revascularization.4 The prevalence of subclavian artery stenosis in hemodialysis patients is considered to be higher than other patients because of an increased incidence of peripheral artery disease in these patients. Therefore, it is important to assess the subclavian artery using imaging modalities, such as computed tomographic angiography or magnetic resonance angiography, particularly in hemodialysis patients who are referred for coronary revascularization. Kato et al. reported that preoperative LITA angiography demonstrated retrograde flow during the diastolic phase in a hemodialysis patient with left upper extremity arteriovenous fistula, and coronary subclavian steal syndrome is considered to be caused by the presence of a high-flow arteriovenous fistula ipsilateral to the ITA.3,6 A high-flow arteriovenous fistula draws flow away from a relatively higher resistance zone such as the coronary artery where the ITA graft is anastomosed to the lower resistance zone such as a vein or to the hemodialysis circuit, particularly during hemodialysis. This can cause symptoms of angina even after successful coronary revascularization. However, Rahbar et al.7 reported no significant changes in the Doppler flow hemodynamics of the ipsilateral or contralateral ITA after manual occlusion of the arteriovenous fistula at rest and during hemodialysis. Therefore, the existence of the coronary subclavian steal syndrome in the absence of subclavian artery stenosis is still debatable. In our case, assessment of the LITA to LAD anastomoses using transit-time graft flow measurements revealed that the flow pattern significantly changed after manual occlusion of the arteriovenous fistula ipsilateral to the ITA. As a result, we were able to diagnose coronary subclavian steal syndrome associated with the high-flow left upper extremity arteriovenous fistula during the surgery. Ligation of the arteriovenous fistula was considered during the surgery, but that strategy was abandoned due to the loss of very
DISCUSSION Two distinct pathophysiological processes may lead to coronary subclavian steal syndrome in hemodialysis patients. First, the presence of a significant stenosis in the proximal part of the subclavian artery can cause a steal phenomenon when the ITA ipsilateral to the arteriovenous fistula is used as a graft for revascularization.5 Second, the presence of a high-shunt flow in the arteriovenous fistula ipsilateral to the ITA leads to coronary subclavian steal syndrome even without subclavian artery stenosis.6
Figure 2. Transit-time graft flow measurements after application of sphygmomanometer cuffs to the left upper extremity to diagnose coronary subclavian steal syndrome associated with left upper extremity arteriovenous fistula. During application of the cuffs, graft flow was improved with a diastolic flow pattern associated with low PI.
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important access for hemodialysis. Consequently, we decided to use LITA as a free graft from the ascending aorta to the LAD. Preoperative ipsilateral ITA and subclavian artery angiography is mandatory in hemodialysis patients receiving coronary revascularization. When ipsilateral subclavian artery stenosis is observed, stenting of the proximal subclavian artery stenosis may be performed in order to utilize ipsilateral ITA for grafting. Alternatively contralateral ITA or free ITA grafts must be utilized. However, preoperative prediction of the occurrence of coronary subclavian steal syndrome due to high flow arteriovenous fistula is still difficult. Therefore, we strongly recommend intraoperative assessment of the ITA graft using transit-time graft flow measurements combined with fluorescence imaging. When an inadequate flow with unacceptable flow pattern is observed in the ITA, additional assessment using fluorescence imaging might be helpful. Intraoperative re-anastomosis should be performed when the possibility of coronary subclavian steal syndrome exists. In addition, in hemodialysis patients who received an ITA graft ipsilateral to the arteriovenous fistula, careful postoperative monitoring for symptoms of angina during dialysis is very important.
J CARD SURG 2015;30:154–156
REFERENCES 1. Ura M, Sakata R, Nakayama Y, et al: The impact of chronic renal failure on atherosclerosis of the internal thoracic arteries. Ann Thorac Surg 2001;71:148–151. 2. Gaudino M, Serricchio M, Luciani N, et al: Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula. Circulation 2003;107:2653–2655. 3. Kato H, Ikawa S, Hayashi A, et al: Internal mammary artery steal in a dialysis patient. Ann Thorac Surg 2003;75:270– 271. 4. Carrascal Y, Arroyo J, Fuertes JJ, et al: Massive coronary subclavian steal syndrome. Ann Thorac Surg 2010;90: 1004–1006. 5. Nanda S, Longo S, Pamula J, et al: Recurrent pulmonary edema induced by coronary-subclavian steal syndrome during hemodialysis. Eur J Cardiothorac Surg 2009;35:740– 742. 6. Crowley SD, Butterly DW, Peter RH, et al: Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis 2002;40:852–855. 7. Rahbar R, McGee WR, Birdas TJ, et al: Upper extremity arteriovenous fistulas induce modest hemodynamic effect on the in situ internal thoracic artery. Ann Thorac Surg 2006;81:145–147.
