Catheterization and Cardiovascular Diagnosis 25161-1 63 (1992)
lnterventional Cardiology Rounds Subclavian Balloon Angioplasty in the Management of the Coronary-Subclavian Steal Syndrome From the Division of Cardiology and Nephrology, Department of Medicine, Medical College of Virginia, Richmond.
Michael Belz, MD, John J. Marshall, MD, Michael J. Cowley, MD, and George W. Vetrovec, MD INTRODUCTION
The coronary-subclavian steal phenomenon though an internal mammary artery has been previously described [ 1-12] with reported correction by subclavian-carotid artery bypass grafting. Herein we describe a case which was corrected by percutaneous transluminal angioplasty of the stenosed left subclavian artery.
CASE REPORT
The patient is a 72 year old male with coronary artery disease status post saphenous vein grafts to his posterior descending artery (PDA) and third obtuse marginal with a left internal mammary (LIMA) artery bypass graft to his left anterior descending artery 1% years prior to the present admission. One year prior to the present admission the patient presented with recurrent angina. Coronary and subclavian angiography revealed a patent LIMA graft to the left anterior descending (LAD) with severe competitive flow from the native LAD. There was also a severe proximal subclavian artery stenosis. The competitive flow was thought to be secondary to steal from the native system. Percutaneous transluminal angioplasty (F'TCA) of the subclavian artery was performed through a left brachial approach with a 5 mm balloon. This was tolerated well with resolution of the competitive flow and his anginal symptoms. Patient did well until this admission when he presented with recurrence of rest angina. At cardiac catheterization the hemodynamics were normal. There was inferior and anterior hypokinesis with a calculated ejection fraction of 35%. The left main was normal. The native LAD had a 70% proximal stenosis. The circumflex was occluded proximally with obtuse 0 1992 Wiley-Liss, Inc.
marginal filling from the LAD IMA graft and native LAD. The right coronary artery and its graft were occiuded proximally. The distal RCA filled via conus branch and left coronary system collaterals. The LIMA was patent to the LAD. The left subclavian artery had approximately a 50% stenosis with a 20 mm Hg peak systolic mean gradient as measured by a 7F diagnostic coronary catheter. Retrograde flow occurred into the LIMA graft during LAD injections in addition to definite retrograde flow in the LIMA during LIMA injections representing LIMA-LAD steal. Percutaneous transluminal angioplasty of his left subclavian artery was performed through the left brachial artery. A .014 angioplasty guide wire was passed across the stenosis and first a 5 mm followed by a 6 mm balloon was inflated resulting in an angiographically improved lumen, no residual gradient, and abolishment of the angiographic steal phenomenon in the LIMA. The patient was subsequently discharged home angina free (Figs. 1, 2). DISCUSSION Subclavian-LIMA Steal
Coronary-subclavian steal following use of mammary arteries for coronary artery bypass grafting has been described [ 1-12]. This phenomenon occurs when the ipsilateral subclavian artery has a preexisting or develops a significant stenosis proximal to the internal mammary
Received and accepted June 18, 1991, Address reprint requests to George W . Vetrovec, M.D., Box 36, MCV Station, Richmond, VA 23298.
162
Belz et al. TABLE 1. Reported 13 Cases of Subclavian LIMA Steal Corrected by Carotid Subclavian Bypass‘ Patient No.
Author Harjola and Valle [ I ] Tyras and Barner [2] Brown [3j\ Bashor et ai. T4] Tarazi et al. [5] Byrnes 161 Niemera et at. [7] Valentine et al. [S] Marshall et al. 191 Mclvor et al. [lo] Kerbert et al. [ I I] Olsen et al. [ 121
.‘?
1
2 3 4 5 6 7 8 9 10
11 12 13
Angina
Outcome
No No No
SV SV Dacron
Yes Yes Yes Yes Yes Yes Yes Yes Yes
IIA FTFE PTFE
sv VS Dacron
sv NS PTFE
Successful Successful Successful Died Successful Successful Successful Successful Successful Successful Successful Successful Successful
*Abbreviations: SV, saphenous vein; IIA. internal iliac artery; FTFE. polytetrafluotoethylene; IVS, not stated.
Fig. 1. Sequential frames illustrating LIMNLAD steal phenomena. a: End injection showing proximal contrast filling of LIMA (arrow) consistent with downstream contrast flow. c: Proximal LIMA contrast refilling (arrow) during the same cardiac cycle without further injection demonstrating retrograde LIMA flow (steal).
subclavian steal from a series of 450 patients who had undergone LIMA grafting to a coronary artery (incidence 0.4%).These asymptomatic patients were discovered on follow-up by blood pressure measurements in both arms. Another asymptomatic case was discovered by routine post-operative coronary angiography [I]. A fourth patient died in the operating room secondary to ischemia from unrecognized coronary subclavian steal [3]. There are now ten reported cases of coronary-subclavian steal presenting with angina pectoris [4-121. All previous surviving cases were corrected with carotid subclavian bypass with resolution of symptoms (see Table I). Our patient is the first reported case to be corrected by percutaneous transluminal angioplasty of the subclavian artery. Of note is the fact that significant functional impairment was observed despite a low translesion gradient. This suggests that the high coronary flow volume required by the patient who collateralized a major portion of his myocardium through the LAD was functionally reduced prior to successful PTA.
Subclavian PTA The brachial approach for PTA of subclavian arteries has been demonstrated to be useful for treatment of arm claudication or neurological symptoms secondary to subclavian artery stenosis in a recent study [ 131. This procedure was also performed as a measure to prevent corartery used for bypass grafting. If the native artery is not onary-subclavian steal in planned coronary bypass completely occluded, blood flow may occur antegrade procedures involving subclavian stenoses proximal to the through the native artery and retrograde through the internal mammary artery origin. All 11 occlusions and mammary artery. This “steals” blood supply from the 22 stenoses were successfully dilated. There were no native coronary circulation distal to the anastomosis. episodes of distal embolization, neurological events, or This may be asymptomatic or may manifest itself as abrupt closure of the subclavian artery. Follow-up data obtained in 22 of the 27 patients over myocardial ischemia. Tyras and Barner [2] reported two cases of coronary- a mean time of 28 months revealed a cumulative patency Fig. 2. Top reveals an eccentric proximal left subclavian stenosis (arrowhead) pre angioplasty. Bottom demonstrates the post dilitation result.
PTCA for Coronary-Subclavian Steal Syndrome
rate of 95%. There were two recurrent symptomatic stenoses which were successfully redilated. In polled data from previous case reports of PTA of the subclavian and innominate arteries totaling 174 patients and 183 lesions, the immediate success rate is 84% and the long term clinical patency is 90% [ 131. Restenosis in our patient may have been the result of inadequate initial dilatation on the first procedure as only a 5 mm balloon was used with a resultant modest degree of residual stenosis. The previous reluctance to utilize this procedure on the brachiocephalic vessels secondary to the possibility of CNS embolism has proven to be largely unwarranted. There is only one case report of embolization to the vetebral artery resulting in a neurological deficit [ 141 out of 174 patients (183 lesions). This may be partly because the flow direction in the ipsilateral vetebral artery, at first retrograde, reverses over several minutes after PTA of the subclavian artery presumably protecting against CNS embolism [ 151. One consideration during subclavian PTA for coronary disease is potential myocardial ischemia if the subclavian occludes during PTA. However, the fact that the native LAD in this patient was only 70% stenosed provided some assurance that minimal flow could have been preserved though the LAD to the myocardium in the event of subclavian occlusion and need for urgent surgery. Surgical Results Surgical correction by carotid subclavian bypass provides relief in approximately 75% of patients [ 181. Carotid-subclavian bypass has an associated mortality of 5% with a 15 to 25% complication rate including stroke, neck lymph fistula, phrenic nerve palsy, and Homer syndrome [ 16-1 81. In the 13 patients with coronary-subclavian steal treated in this fashion the short term success has been 100% with no reported complications. SUMMARY The syndrome of coronary-subclavian steal presenting with angina pectoris after coronary revascularization with the mammary arteries is not common. This disorder should be suspected in post LIMA patients with blood pressure differences between the arms and confirmed by angiography. PTA of the subclavian artery via the brachial approach, in appropriately selected patients, offers potential advantages over carotid subclavian bypass including an apparent lower complication rate with equally good results. Recurrences, which are apt to be more common after PTA versus carotid subclavian bypass, are easily managed with repeat dilatation. This course of
163
management in our patient resulted in an excellent clinical outcome without complication. This report emphasizes the importance of considering subclavian stenosis in patients with prior LIMA bypass grafting, particularly when the ipsilateral ann blood pressure is reduced. In such cases, subclavian PTA offers a reasonable nonsurgical approach for correction. REFERENCES I . Harjola PT, Valle M: The importance of aortic arch or subclavian angiography before coronary reconstruction. Chest 66:463, 1974. 2. Tyras DH, Barner HB: Coronary-subclavian steal. Arch Surg 112:1125, 1977. 3. Brown AH: Coronary steal by internal mammary grafting with subclavian stenosis. J Thorac Cardiovasc Surg 73:690. 1977. 4. Bashour TT,Crew J, Kabani SS, et al.: Symptomatic coronary and cerebral steal after internal mammary-coronary bypass. Am Heart J 108:177, 1984. 5 . Tarazi RY, O'Hara PJ, Loop FD: Symptomatic coronary-subclavian steal corrected by carotid subclavian bypass. J Vasc Surg 3:669, 1986. 6. Byrnes JF: Case report: LAD-LOMA steal sundrome. Assoc Physicians Assistant CV Surg 5(3):9, 1986. 7. Niemera ML, Haft JI, Goldstein JE, Hobson RW: Retrograde internal mammary artery flow and resistant angina pectoris: clues to the coronary-subclavian steal syndrome. Cathet Cardiovasc Diagn 12:93, 1986. 8. Valentine RJ, Fry RE, Wheelan RK, et al.: Coronary-subclavian steal from reversed flow in an internal mammary artery used for coronary bypass. Am J Cardiol 59:719, 1988. 9. Marshall WG, Miller EC, Kouchoukos NT: The coronary subclavian steal syndrome: report of a case and recommendations for prevention and management. Ann Thorac Surg 46:93, 1988. 10. Mclvor ME, Williams GM, Brinker J: Subclavian-coronary steal through a LIMA-to-LAD bypass graft. Cathet Cardiovasc Diagn 14:100, 1988. 1 I . Kerbert C, Delwig H, Donders HPC, et al.: Recidieve angina pectoris na een mammaria-coronary-operatie als gevolg van stenoserin van de arterie subclavia. Hart Bull 18:127, 1987. 12. Olsen CO, Dunton RF, Maggs PR, Lahey SJ: Review of coronary-subclavian steal following internal mammary artery-coronary artery bypass surgery. Ann Thorac Surg 46:675-678, 1988. 13. Dorros G, Lewin RF, Jamnadas P, Mathiak LM: Peripheral transluminal angioplasty of the subclavian and innominate arteries utilizing the brachial approach: Acute outcome and follow-up. Cathet Cardiovasc Diagn 19:71, 1990. 14. Motarjame A, Keifer J, Zuska A: Percutaneous transluminal angioplasty of the brachiocephalic arteries. AJR 138:457, 1982. 15. Ringelstein EB, Zeumer H: Delayed reversal of vertebral artery blood flow following percutaneou transluminal angioplasty for subclavian steal syndrome. Neuroradiology 26:189, 1984. 16. Beebe HE, Stark C, Johnson ML, Jolly PC, Hill LD: Choices of operation for subclavian-vertebral arterial disease. Am J Surg 139:616, 1980. 17. Herring M: The subclavian steal syndrome: A review. Am Surg 43:220, 1977. 18. Fields WS, Lemak NA: Joint study of extracranial arterial occlusion. VII. Subclavian steal: A review of 168 cases. JAMA 222: 1139. 1972.
lnterventional Cardiology Rounds Subclavian Balloon Angioplasty in the Management of the Coronary-Subclavian Steal Syndrome From the Division of Cardiology and Nephrology, Department of Medicine, Medical College of Virginia, Richmond.
Michael Belz, MD, John J. Marshall, MD, Michael J. Cowley, MD, and George W. Vetrovec, MD INTRODUCTION
The coronary-subclavian steal phenomenon though an internal mammary artery has been previously described [ 1-12] with reported correction by subclavian-carotid artery bypass grafting. Herein we describe a case which was corrected by percutaneous transluminal angioplasty of the stenosed left subclavian artery.
CASE REPORT
The patient is a 72 year old male with coronary artery disease status post saphenous vein grafts to his posterior descending artery (PDA) and third obtuse marginal with a left internal mammary (LIMA) artery bypass graft to his left anterior descending artery 1% years prior to the present admission. One year prior to the present admission the patient presented with recurrent angina. Coronary and subclavian angiography revealed a patent LIMA graft to the left anterior descending (LAD) with severe competitive flow from the native LAD. There was also a severe proximal subclavian artery stenosis. The competitive flow was thought to be secondary to steal from the native system. Percutaneous transluminal angioplasty (F'TCA) of the subclavian artery was performed through a left brachial approach with a 5 mm balloon. This was tolerated well with resolution of the competitive flow and his anginal symptoms. Patient did well until this admission when he presented with recurrence of rest angina. At cardiac catheterization the hemodynamics were normal. There was inferior and anterior hypokinesis with a calculated ejection fraction of 35%. The left main was normal. The native LAD had a 70% proximal stenosis. The circumflex was occluded proximally with obtuse 0 1992 Wiley-Liss, Inc.
marginal filling from the LAD IMA graft and native LAD. The right coronary artery and its graft were occiuded proximally. The distal RCA filled via conus branch and left coronary system collaterals. The LIMA was patent to the LAD. The left subclavian artery had approximately a 50% stenosis with a 20 mm Hg peak systolic mean gradient as measured by a 7F diagnostic coronary catheter. Retrograde flow occurred into the LIMA graft during LAD injections in addition to definite retrograde flow in the LIMA during LIMA injections representing LIMA-LAD steal. Percutaneous transluminal angioplasty of his left subclavian artery was performed through the left brachial artery. A .014 angioplasty guide wire was passed across the stenosis and first a 5 mm followed by a 6 mm balloon was inflated resulting in an angiographically improved lumen, no residual gradient, and abolishment of the angiographic steal phenomenon in the LIMA. The patient was subsequently discharged home angina free (Figs. 1, 2). DISCUSSION Subclavian-LIMA Steal
Coronary-subclavian steal following use of mammary arteries for coronary artery bypass grafting has been described [ 1-12]. This phenomenon occurs when the ipsilateral subclavian artery has a preexisting or develops a significant stenosis proximal to the internal mammary
Received and accepted June 18, 1991, Address reprint requests to George W . Vetrovec, M.D., Box 36, MCV Station, Richmond, VA 23298.
162
Belz et al. TABLE 1. Reported 13 Cases of Subclavian LIMA Steal Corrected by Carotid Subclavian Bypass‘ Patient No.
Author Harjola and Valle [ I ] Tyras and Barner [2] Brown [3j\ Bashor et ai. T4] Tarazi et al. [5] Byrnes 161 Niemera et at. [7] Valentine et al. [S] Marshall et al. 191 Mclvor et al. [lo] Kerbert et al. [ I I] Olsen et al. [ 121
.‘?
1
2 3 4 5 6 7 8 9 10
11 12 13
Angina
Outcome
No No No
SV SV Dacron
Yes Yes Yes Yes Yes Yes Yes Yes Yes
IIA FTFE PTFE
sv VS Dacron
sv NS PTFE
Successful Successful Successful Died Successful Successful Successful Successful Successful Successful Successful Successful Successful
*Abbreviations: SV, saphenous vein; IIA. internal iliac artery; FTFE. polytetrafluotoethylene; IVS, not stated.
Fig. 1. Sequential frames illustrating LIMNLAD steal phenomena. a: End injection showing proximal contrast filling of LIMA (arrow) consistent with downstream contrast flow. c: Proximal LIMA contrast refilling (arrow) during the same cardiac cycle without further injection demonstrating retrograde LIMA flow (steal).
subclavian steal from a series of 450 patients who had undergone LIMA grafting to a coronary artery (incidence 0.4%).These asymptomatic patients were discovered on follow-up by blood pressure measurements in both arms. Another asymptomatic case was discovered by routine post-operative coronary angiography [I]. A fourth patient died in the operating room secondary to ischemia from unrecognized coronary subclavian steal [3]. There are now ten reported cases of coronary-subclavian steal presenting with angina pectoris [4-121. All previous surviving cases were corrected with carotid subclavian bypass with resolution of symptoms (see Table I). Our patient is the first reported case to be corrected by percutaneous transluminal angioplasty of the subclavian artery. Of note is the fact that significant functional impairment was observed despite a low translesion gradient. This suggests that the high coronary flow volume required by the patient who collateralized a major portion of his myocardium through the LAD was functionally reduced prior to successful PTA.
Subclavian PTA The brachial approach for PTA of subclavian arteries has been demonstrated to be useful for treatment of arm claudication or neurological symptoms secondary to subclavian artery stenosis in a recent study [ 131. This procedure was also performed as a measure to prevent corartery used for bypass grafting. If the native artery is not onary-subclavian steal in planned coronary bypass completely occluded, blood flow may occur antegrade procedures involving subclavian stenoses proximal to the through the native artery and retrograde through the internal mammary artery origin. All 11 occlusions and mammary artery. This “steals” blood supply from the 22 stenoses were successfully dilated. There were no native coronary circulation distal to the anastomosis. episodes of distal embolization, neurological events, or This may be asymptomatic or may manifest itself as abrupt closure of the subclavian artery. Follow-up data obtained in 22 of the 27 patients over myocardial ischemia. Tyras and Barner [2] reported two cases of coronary- a mean time of 28 months revealed a cumulative patency Fig. 2. Top reveals an eccentric proximal left subclavian stenosis (arrowhead) pre angioplasty. Bottom demonstrates the post dilitation result.
PTCA for Coronary-Subclavian Steal Syndrome
rate of 95%. There were two recurrent symptomatic stenoses which were successfully redilated. In polled data from previous case reports of PTA of the subclavian and innominate arteries totaling 174 patients and 183 lesions, the immediate success rate is 84% and the long term clinical patency is 90% [ 131. Restenosis in our patient may have been the result of inadequate initial dilatation on the first procedure as only a 5 mm balloon was used with a resultant modest degree of residual stenosis. The previous reluctance to utilize this procedure on the brachiocephalic vessels secondary to the possibility of CNS embolism has proven to be largely unwarranted. There is only one case report of embolization to the vetebral artery resulting in a neurological deficit [ 141 out of 174 patients (183 lesions). This may be partly because the flow direction in the ipsilateral vetebral artery, at first retrograde, reverses over several minutes after PTA of the subclavian artery presumably protecting against CNS embolism [ 151. One consideration during subclavian PTA for coronary disease is potential myocardial ischemia if the subclavian occludes during PTA. However, the fact that the native LAD in this patient was only 70% stenosed provided some assurance that minimal flow could have been preserved though the LAD to the myocardium in the event of subclavian occlusion and need for urgent surgery. Surgical Results Surgical correction by carotid subclavian bypass provides relief in approximately 75% of patients [ 181. Carotid-subclavian bypass has an associated mortality of 5% with a 15 to 25% complication rate including stroke, neck lymph fistula, phrenic nerve palsy, and Homer syndrome [ 16-1 81. In the 13 patients with coronary-subclavian steal treated in this fashion the short term success has been 100% with no reported complications. SUMMARY The syndrome of coronary-subclavian steal presenting with angina pectoris after coronary revascularization with the mammary arteries is not common. This disorder should be suspected in post LIMA patients with blood pressure differences between the arms and confirmed by angiography. PTA of the subclavian artery via the brachial approach, in appropriately selected patients, offers potential advantages over carotid subclavian bypass including an apparent lower complication rate with equally good results. Recurrences, which are apt to be more common after PTA versus carotid subclavian bypass, are easily managed with repeat dilatation. This course of
163
management in our patient resulted in an excellent clinical outcome without complication. This report emphasizes the importance of considering subclavian stenosis in patients with prior LIMA bypass grafting, particularly when the ipsilateral ann blood pressure is reduced. In such cases, subclavian PTA offers a reasonable nonsurgical approach for correction. REFERENCES I . Harjola PT, Valle M: The importance of aortic arch or subclavian angiography before coronary reconstruction. Chest 66:463, 1974. 2. Tyras DH, Barner HB: Coronary-subclavian steal. Arch Surg 112:1125, 1977. 3. Brown AH: Coronary steal by internal mammary grafting with subclavian stenosis. J Thorac Cardiovasc Surg 73:690. 1977. 4. Bashour TT,Crew J, Kabani SS, et al.: Symptomatic coronary and cerebral steal after internal mammary-coronary bypass. Am Heart J 108:177, 1984. 5 . Tarazi RY, O'Hara PJ, Loop FD: Symptomatic coronary-subclavian steal corrected by carotid subclavian bypass. J Vasc Surg 3:669, 1986. 6. Byrnes JF: Case report: LAD-LOMA steal sundrome. Assoc Physicians Assistant CV Surg 5(3):9, 1986. 7. Niemera ML, Haft JI, Goldstein JE, Hobson RW: Retrograde internal mammary artery flow and resistant angina pectoris: clues to the coronary-subclavian steal syndrome. Cathet Cardiovasc Diagn 12:93, 1986. 8. Valentine RJ, Fry RE, Wheelan RK, et al.: Coronary-subclavian steal from reversed flow in an internal mammary artery used for coronary bypass. Am J Cardiol 59:719, 1988. 9. Marshall WG, Miller EC, Kouchoukos NT: The coronary subclavian steal syndrome: report of a case and recommendations for prevention and management. Ann Thorac Surg 46:93, 1988. 10. Mclvor ME, Williams GM, Brinker J: Subclavian-coronary steal through a LIMA-to-LAD bypass graft. Cathet Cardiovasc Diagn 14:100, 1988. 1 I . Kerbert C, Delwig H, Donders HPC, et al.: Recidieve angina pectoris na een mammaria-coronary-operatie als gevolg van stenoserin van de arterie subclavia. Hart Bull 18:127, 1987. 12. Olsen CO, Dunton RF, Maggs PR, Lahey SJ: Review of coronary-subclavian steal following internal mammary artery-coronary artery bypass surgery. Ann Thorac Surg 46:675-678, 1988. 13. Dorros G, Lewin RF, Jamnadas P, Mathiak LM: Peripheral transluminal angioplasty of the subclavian and innominate arteries utilizing the brachial approach: Acute outcome and follow-up. Cathet Cardiovasc Diagn 19:71, 1990. 14. Motarjame A, Keifer J, Zuska A: Percutaneous transluminal angioplasty of the brachiocephalic arteries. AJR 138:457, 1982. 15. Ringelstein EB, Zeumer H: Delayed reversal of vertebral artery blood flow following percutaneou transluminal angioplasty for subclavian steal syndrome. Neuroradiology 26:189, 1984. 16. Beebe HE, Stark C, Johnson ML, Jolly PC, Hill LD: Choices of operation for subclavian-vertebral arterial disease. Am J Surg 139:616, 1980. 17. Herring M: The subclavian steal syndrome: A review. Am Surg 43:220, 1977. 18. Fields WS, Lemak NA: Joint study of extracranial arterial occlusion. VII. Subclavian steal: A review of 168 cases. JAMA 222: 1139. 1972.
