Catheterization and Cardiovascular Diagnosis 26:12-14 (1992)
Symptomatic Angina Secondary to Coronary-Subclavian Steal Syndrome Treated Successfully by Percutaneous Transluminal Angioplasty of the Subclavian Artery Harry Feld, MD, Paul Nathan, MD, Dilsukh Raninga, MD, and Jacob Shani, MD Subclavian artery stenosis causing severely symptomatic angina in a patient with a previous left Internal mammary artery bypass to the left anterior descending artery was treated successfully with percutaneous transluminal angioplasty. Baseline arterlography clearly revealed subclavian and coronary steal by evidence of competitive flow of nonopacified blood from the left vertebral artery. Although there was a difference of only 15 mm Hg between the right and left brachialarteries, there was a palpable difference in the upstroke of these pulses. The stenosls in the subclavian artery was successfully dilated with percutaneous transluminal angloplasty. Angiographic evidence of subclavian steal resolved following balloon dilatation, and the patient’s angina was completely resolved. Q 1992 Wllsy-Llu, Inc.
Key words: internal mammary artery bypass, symptomatic angina, stenosis
INTRODUCTION
The left internal mammary artery has become the preferred conduit used to bypass the left anterior descending artery [ 11. While hemodynamically significant stenosis of the left subclavian artery causing a subclavian steal syndrome is well described [2], symptomatic angina in patients with proximal subclavian artery stenosis and prior left internal mammary bypass surgery to the left anterior descending artery is less well known [3-81. While this has traditionally been treated with carotidsubclavian bypass surgery, the complication rate of this procedure is in the range of 25 percent [4]. We, therefore, performed percutaneous transluminal angioplasty of the subclavian artery, which successfully resolved the subclavian steal and angina.
CASE PRESENTATION
The patient was an 84-year-old gentleman who presented with 3 months of exertional angina that was particulary exacerbated with upper-extremity exercise. The patient underwent a 5-vessel bypass 1 year prior to admission. This included a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the distal right coronary artery, the acute marginal branch of the right coronary artery, the obtuse marginal of the left circumflex, and the diagonal branch of the left anterior descending artery. While the patient’s symptoms were accompanied by painful dysesthesia of the left hand, he did not have 0 1992 Wiley-Liss, Inc.
dizziness, vertigo, visual blurring, or ataxia. The patient underwent dipyridamole-thallium scintigraphy, which displayed severe reversible ischemia in the anterior wall. The inferior and lateral walls appeared to be infarcted. Physicial examination revealed a blood pressure of 1 I5/ 70 mm Hg in the right arm with a simultaneous pressure of 100/70 mm Hg in the left arm. Despite this, there was a palpable difference in the 2 brachial pulses, with the left brachial pulse being somewhat diminished with a delayed upstroke. There were no audible bruits over the carotid or subclavian arteries. The rest of the physical examination was unremarkable. The patient was then referred for cardiac catheterization, which revealed that all of the saphenous vein grafts, except for the graft to the obtuse marginal branch, were occluded. While attempting to selectively cannulate the left internal mammary artery, the catheter could not be advanced into the left subclavian artery. Aortic arch angiography revealed an 85% stenosis in the proximal portion of the left subclavian artery with a moderate stenosis at the origin of the left vertebral artery. The left internal mammary artery
Maimonides Medical Center, Division of Cardiology, SUNY Health Science Center, Brooklyn, New York.
Received September 18. 1991; revision accepted November 18. 1991. Address reprint requests to Harry Feld. M.D., Associate Director, Cardiac Catheterization Laboratory, Maimonides Medical Center, SUNY Health Science Center, 4802 Tenth Avenue, Brooklyn, NY 11219.
Treatment with Percutaneous Transluminal Angioplasty
Fig. 1 Baseline arteriography revealing a severe stenosis in the proximalleft subclavian artery. Arrow points to the vertebral artery which is filled mostly with nonopacified dye due to competitive flow. Compare with Fig. 3.
was widely patent with only mild disease in the LAD distal to the anastomosis (Fig. 1). Precutaneous angioplasty of the left subclavian artery was performed via the femoral approach. The right femoral artery was cannulated with an 8F arterial sheath. The patient was then heparinized with 10,000 U heparin. The origin of the left subclavian artery was then cannulated with a 5F multipurpose catheter. The lesion could not be crossed with 0.035 wire but was easily crossed with a 0.014 high-torque, floppy exchange wire. The multipurpose catheter was then removed and exchanged for an 18K Medtronic 3.0 mrn balloon dilatation catheter. We predilated the lesion with this balloon without guiding catheter support. The balloon was then removed and the 5F multipurpose catheter was advanced over the wire distal to the stenosis. The 0.014 high-torque, floppy exchange wire was removed and a 0.035 exchange J wire was placed through the catheter to the distal left subclavian artery. An 8 mm Meditech 3 cm long balloon dilatation catheter was advanced over the wire. The balloon was inflated for 5 min at 5 atm pressure (Fig. 2). Final arteriography revealed no residual stenosis. There was normalization of antegrade contrast flow up the left vertebral artery without competitive flow (Fig. 3). Clinical follow-up revealed that the blood pressure disparity between the 2 brachial arteries was abolished, and the patient’s angina was totally resolved. DISCUSSION The subclavian steal syndrome is well described and is due to a stenosis of the left subclavian artery, leading to reversal of flow in the vertebral artery. This can lead to
13
Fig. 2. 8 mm balloon inflated across the stenosis.
Fig. 3. Final result. Note good antegrade flow in both the vertebral and internal mammary arteries.
symptoms of lightheadedness and cerebral insufficiency exacerbated with left arm exercise [2]. The coronarysubclavian steal syndrome leading to angina is less well described. However, with the increasing popularity of the internal mammary artery as the conduit of choice for bypass, the coronary-subclavian steal syndrome is being seen with increasing frequency, and there are now a total of 12 cases reported in the literature [3-6,8]. In these reported cases, there was at least a 22 mm Hg difference in the brachial systolic pressures [ 5 ] , and most of these patients underwent carotid subclavian artery bypass for relief of symptoms. However, the surgical complication rate of this procedure is reported to be 2370, and only 2 cases of coronary-subclavian steal syndrome corrected by percutaneous transluminal angioplasty are reported in the surgical literature [6,8]. While a thromboernbolic
14
Feld et al.
Proudfit WL: Influence of the internal mammary artery graft on 10 event following any angioplasty is a known complicayear survival and other cardiac events. N Engl J Med 314:1-5, tion, its incidence is very low. Following percutaneous 1986. transluminal angioplasty for subclavian steal, there is 2. Killen DA, Foster JH, Gobbel WG Jr.. Stephenson SE, Collius delayed reversal of flow [7]. This, therefore, further reHA, Billings m,Scott HA: The subclavian steal syndrome. J duces the risk of a cerebral thromboembolic complicaThorac Cardiovasc Surg 51539, 1966. 3. Olsen C, Dunton R, Maggs P, Lahey S: Review of coronarytion. subclavian steal following internal mammary artery-coronary arWe conclude that the subclavian-coronary steal synbypass surgery. Ann Thorac Surg 46:67-678. 1988. drome can occur even when the disparity of the systolic 4 . tery Beebe H. Stark R, Johnson M: Choices of operation for subclavian brachial pressures is minimal. Therefore, routine screenvertebral artery disease. Am J Surg 139:616-623, 1980. ing of bilateral brachial artery pressures does not always 5. Tarazi RY, O'hara PJ, Loop FD: Symptomatic coronary-subclavian steal following internal mammary artery corconary artery bydetect subclavian artery stenosis. This may be due to pass surgery. J Vasc Surg 3:669-672, 1986. bilateral atherosclerosis of the subclavian arteries. Per6. Ishii K, Hirota Y, Kita Y, Kawamura K, Suma H, Takeuchi A: cutaneous angioplasty can be performed safely to correct Coronary-subclavian steal corrected with percutaneous translumithis syndrome. Predilatation using coronary equipment nal angioplasty. J Cardiovasc Surg 32:275, 1991. allows passage of the 0.035 wire and peripheral angio- 7. Ringelstein EB, Zeumer H: Delayed reversal of vertebral artery blood flow following percutaneous transluminal angioplasty for plasty equipment.
REFERENCES I . Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goorsmastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC.
subclavian steal syndrome. Neuroradiology 26: 189-198, 1984. 8. Shapira S , Braun SD, Brahmaji P, Patel G, Rotman H: Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery. J Am Coil Cardiol 18:1120-1123, 1991.
Symptomatic Angina Secondary to Coronary-Subclavian Steal Syndrome Treated Successfully by Percutaneous Transluminal Angioplasty of the Subclavian Artery Harry Feld, MD, Paul Nathan, MD, Dilsukh Raninga, MD, and Jacob Shani, MD Subclavian artery stenosis causing severely symptomatic angina in a patient with a previous left Internal mammary artery bypass to the left anterior descending artery was treated successfully with percutaneous transluminal angioplasty. Baseline arterlography clearly revealed subclavian and coronary steal by evidence of competitive flow of nonopacified blood from the left vertebral artery. Although there was a difference of only 15 mm Hg between the right and left brachialarteries, there was a palpable difference in the upstroke of these pulses. The stenosls in the subclavian artery was successfully dilated with percutaneous transluminal angloplasty. Angiographic evidence of subclavian steal resolved following balloon dilatation, and the patient’s angina was completely resolved. Q 1992 Wllsy-Llu, Inc.
Key words: internal mammary artery bypass, symptomatic angina, stenosis
INTRODUCTION
The left internal mammary artery has become the preferred conduit used to bypass the left anterior descending artery [ 11. While hemodynamically significant stenosis of the left subclavian artery causing a subclavian steal syndrome is well described [2], symptomatic angina in patients with proximal subclavian artery stenosis and prior left internal mammary bypass surgery to the left anterior descending artery is less well known [3-81. While this has traditionally been treated with carotidsubclavian bypass surgery, the complication rate of this procedure is in the range of 25 percent [4]. We, therefore, performed percutaneous transluminal angioplasty of the subclavian artery, which successfully resolved the subclavian steal and angina.
CASE PRESENTATION
The patient was an 84-year-old gentleman who presented with 3 months of exertional angina that was particulary exacerbated with upper-extremity exercise. The patient underwent a 5-vessel bypass 1 year prior to admission. This included a left internal mammary artery graft to the left anterior descending artery and saphenous vein grafts to the distal right coronary artery, the acute marginal branch of the right coronary artery, the obtuse marginal of the left circumflex, and the diagonal branch of the left anterior descending artery. While the patient’s symptoms were accompanied by painful dysesthesia of the left hand, he did not have 0 1992 Wiley-Liss, Inc.
dizziness, vertigo, visual blurring, or ataxia. The patient underwent dipyridamole-thallium scintigraphy, which displayed severe reversible ischemia in the anterior wall. The inferior and lateral walls appeared to be infarcted. Physicial examination revealed a blood pressure of 1 I5/ 70 mm Hg in the right arm with a simultaneous pressure of 100/70 mm Hg in the left arm. Despite this, there was a palpable difference in the 2 brachial pulses, with the left brachial pulse being somewhat diminished with a delayed upstroke. There were no audible bruits over the carotid or subclavian arteries. The rest of the physical examination was unremarkable. The patient was then referred for cardiac catheterization, which revealed that all of the saphenous vein grafts, except for the graft to the obtuse marginal branch, were occluded. While attempting to selectively cannulate the left internal mammary artery, the catheter could not be advanced into the left subclavian artery. Aortic arch angiography revealed an 85% stenosis in the proximal portion of the left subclavian artery with a moderate stenosis at the origin of the left vertebral artery. The left internal mammary artery
Maimonides Medical Center, Division of Cardiology, SUNY Health Science Center, Brooklyn, New York.
Received September 18. 1991; revision accepted November 18. 1991. Address reprint requests to Harry Feld. M.D., Associate Director, Cardiac Catheterization Laboratory, Maimonides Medical Center, SUNY Health Science Center, 4802 Tenth Avenue, Brooklyn, NY 11219.
Treatment with Percutaneous Transluminal Angioplasty
Fig. 1 Baseline arteriography revealing a severe stenosis in the proximalleft subclavian artery. Arrow points to the vertebral artery which is filled mostly with nonopacified dye due to competitive flow. Compare with Fig. 3.
was widely patent with only mild disease in the LAD distal to the anastomosis (Fig. 1). Precutaneous angioplasty of the left subclavian artery was performed via the femoral approach. The right femoral artery was cannulated with an 8F arterial sheath. The patient was then heparinized with 10,000 U heparin. The origin of the left subclavian artery was then cannulated with a 5F multipurpose catheter. The lesion could not be crossed with 0.035 wire but was easily crossed with a 0.014 high-torque, floppy exchange wire. The multipurpose catheter was then removed and exchanged for an 18K Medtronic 3.0 mrn balloon dilatation catheter. We predilated the lesion with this balloon without guiding catheter support. The balloon was then removed and the 5F multipurpose catheter was advanced over the wire distal to the stenosis. The 0.014 high-torque, floppy exchange wire was removed and a 0.035 exchange J wire was placed through the catheter to the distal left subclavian artery. An 8 mm Meditech 3 cm long balloon dilatation catheter was advanced over the wire. The balloon was inflated for 5 min at 5 atm pressure (Fig. 2). Final arteriography revealed no residual stenosis. There was normalization of antegrade contrast flow up the left vertebral artery without competitive flow (Fig. 3). Clinical follow-up revealed that the blood pressure disparity between the 2 brachial arteries was abolished, and the patient’s angina was totally resolved. DISCUSSION The subclavian steal syndrome is well described and is due to a stenosis of the left subclavian artery, leading to reversal of flow in the vertebral artery. This can lead to
13
Fig. 2. 8 mm balloon inflated across the stenosis.
Fig. 3. Final result. Note good antegrade flow in both the vertebral and internal mammary arteries.
symptoms of lightheadedness and cerebral insufficiency exacerbated with left arm exercise [2]. The coronarysubclavian steal syndrome leading to angina is less well described. However, with the increasing popularity of the internal mammary artery as the conduit of choice for bypass, the coronary-subclavian steal syndrome is being seen with increasing frequency, and there are now a total of 12 cases reported in the literature [3-6,8]. In these reported cases, there was at least a 22 mm Hg difference in the brachial systolic pressures [ 5 ] , and most of these patients underwent carotid subclavian artery bypass for relief of symptoms. However, the surgical complication rate of this procedure is reported to be 2370, and only 2 cases of coronary-subclavian steal syndrome corrected by percutaneous transluminal angioplasty are reported in the surgical literature [6,8]. While a thromboernbolic
14
Feld et al.
Proudfit WL: Influence of the internal mammary artery graft on 10 event following any angioplasty is a known complicayear survival and other cardiac events. N Engl J Med 314:1-5, tion, its incidence is very low. Following percutaneous 1986. transluminal angioplasty for subclavian steal, there is 2. Killen DA, Foster JH, Gobbel WG Jr.. Stephenson SE, Collius delayed reversal of flow [7]. This, therefore, further reHA, Billings m,Scott HA: The subclavian steal syndrome. J duces the risk of a cerebral thromboembolic complicaThorac Cardiovasc Surg 51539, 1966. 3. Olsen C, Dunton R, Maggs P, Lahey S: Review of coronarytion. subclavian steal following internal mammary artery-coronary arWe conclude that the subclavian-coronary steal synbypass surgery. Ann Thorac Surg 46:67-678. 1988. drome can occur even when the disparity of the systolic 4 . tery Beebe H. Stark R, Johnson M: Choices of operation for subclavian brachial pressures is minimal. Therefore, routine screenvertebral artery disease. Am J Surg 139:616-623, 1980. ing of bilateral brachial artery pressures does not always 5. Tarazi RY, O'hara PJ, Loop FD: Symptomatic coronary-subclavian steal following internal mammary artery corconary artery bydetect subclavian artery stenosis. This may be due to pass surgery. J Vasc Surg 3:669-672, 1986. bilateral atherosclerosis of the subclavian arteries. Per6. Ishii K, Hirota Y, Kita Y, Kawamura K, Suma H, Takeuchi A: cutaneous angioplasty can be performed safely to correct Coronary-subclavian steal corrected with percutaneous translumithis syndrome. Predilatation using coronary equipment nal angioplasty. J Cardiovasc Surg 32:275, 1991. allows passage of the 0.035 wire and peripheral angio- 7. Ringelstein EB, Zeumer H: Delayed reversal of vertebral artery blood flow following percutaneous transluminal angioplasty for plasty equipment.
REFERENCES I . Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goorsmastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC.
subclavian steal syndrome. Neuroradiology 26: 189-198, 1984. 8. Shapira S , Braun SD, Brahmaji P, Patel G, Rotman H: Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery. J Am Coil Cardiol 18:1120-1123, 1991.
