Frequency of subclavian artery stenosis in patients with mammarian artery coronary bypass and suspected coronary artery disease progression.

We retrospectively analyzed patient records of all patients with a history of internal mammarian artery (IMA) coronary bypass undergoing coronary angiography at two cardiovascular centers between January 1st 1999 and December 31st 2019. A total of 11,929 coronary angiographies with or without percutaneous coronary intervention were carried out in 3921 patients. Our analysis revealed 82 (2%) patients with documented subclavian artery stenosis. Of these, 8 (10%) patients were classified as having mild, 18 (22%) moderate, and 56 (68%) severe subclavian artery stenosis. In 7 (9%) patients with subclavian artery stenosis, angiography revealed occlusion of the IMA graft. 26 (32%) patients with severe subclavian artery stenosis underwent endovascular or surgical revasculararization of the subclavian artery. In this retrospective multicenter study, subclavian artery stenosis was a relevant finding in patients with an internal mammarian artery coronary bypass graft undergoing coronary angiography. The development of dedicated algorithms for screening and ischemia evaluation in affected individuals may improve treatment of this potentially underdiagnosed and undertreated condition.

Radiobasilic Versus Brachiobasilic Transposition on the Upper Arm to Avoid Steal Syndrome.

BACKGROUND: Although the proximal radial artery has been reported as an alternative inflow to prevent steal syndrome, brachiobasilic fistula has been reported to be associated with steal syndrome in 10-20% of cases. We aimed to compare proximal radiobasilic arteriovenous fistula (AVF) with brachiobasilic AVFs on the upper arm in terms of steal syndrome and outcomes. MATERIAL AND METHODS: We used our institutional operative record database to identify 94 patients in whom brachiobasilic AVF (n=40) and radiobasilic AVF (n=54) were placed between January 2009 and December 2013. Postoperative complications such as steal syndrome, venous hypertension, and aneurysm were recorded. RESULTS: Steal syndrome was determined to occur less frequently in the radiobasilic AVF group (0% vs. 10%, P=0.03). The rates of other complications (bleeding, aneurysm, venous hypertension) between the 2 groups were similar, as were the patency rates. CONCLUSIONS: Radiobasilic AVF was effective in reducing steal syndrome, with similar early and late outcomes.

Reconstruction of an isolated left subclavian artery in a patient with a right aortic arch and tetralogy of Fallot.

An isolated left subclavian artery (ILSA) is very rarely seen in patients with a right aortic arch. This report describes the case of a 2-year-old boy who underwent ILSA reconstruction during repair of the associated tetralogy of Fallot to prevent future subclavian steal syndrome after surgery.

Simultaneous preoperative brachiocephalic angiography and coronary angiography to prevent coronary-subclavian steal syndrome in coronary surgery candidates.

BACKGROUND: Whether or not preoperative brachiocephalic angiography with left internal mammary artery (LIMA) visualization should be performed at the time of coronary angiography in patients in whom bypass grafting using LIMA is envisaged is still debated. We sought to assess the role of the routine brachiocephalic angiography artery in preventing the coronary-subclavian steal syndrome in patients who are candidates for bypass grafting using LIMA. METHODS: Medical records of 110 patients (mean age 69.3 +/- 8.4 years) who underwent concomitant coronary angiography and brachiocephalic arteriography between May 1998 and December 2002 were reviewed. Stenosis >50%, vessel occlusion, and aneurysm were noted as significant findings. RESULTS: Significant findings were observed in 23/110 patients (20.9%). Five patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. During a mean follow-up of 24.7 +/- 10.7 months, only one patient developed a new subclavian artery disease after bypass grafting using LIMA, and underwent subclavian artery angioplasty. Logistic regression analysis revealed 3-vessel CAD (odds ratio (OR) 9.917 ; 95% confidence interval (CI) 2.2 to 43.8; P = .002), hypercholesterolemy (OR 2.74; CI 95% 1.05 to 7.7; P = .044), and age >65 (OR 3.55; CI 95% 2.2 to 9.2, P = .038) to be predictors of brachiocephalic disease. CONCLUSION: This study suggests that routine angiography of the brachiocephalic arteries at the time of coronary angiography is effective in preventing coronary-subclavian steal syndrome in select patients who are candidates for bypass grafting using LIMA.

Steal syndrome complicating upper extremity hemoaccess procedures: incidence and risk factors.

INTRODUCTION: Steal syndrome is a potentially grave complication of upper extremity hemoaccess (HA) in patients with renal failure. To determine the incidence and risk factors for steal in these patients at the St. Boniface Hospital, Winnipeg, a tertiary care centre for vascular surgery and dialysis, we reviewed data from patients requiring hemodialysis between September 1986 and July 2000. PATIENTS AND METHODS: We excluded all venous catheter and lower extremity procedures. There remained 325 upper extremity procedures in 217 patients. Data were collected from the patients' charts or by interview. First by univariate analysis and then by multivariate analysis for independent risk factors, we studied the effect on the development of steal of age, sex, race diabetes mellitus, hypertension, coronary artery disease or cerebrovascular disease, smoking, proximal procedures based on the brachial artery, distal procedures based on the radial artery, the use of prosthetic graft material and the creation of autologous fistulas. RESULTS: The incidence of steal was 6.2%. The significant independent risk factors were diabetes mellitus (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.39-18.08, p = 0.01) and Aboriginal race (OR 3.59, 95% CI 1.07-12.04, p = 0.04). An increasing risk for each year of advancing age at the time of procedure was suggested but was not significant (OR 1.04, 95% CI 1.00-1.09 p = 0.07). CONCLUSIONS: Patients who are diabetic or Aboriginal are at increased risk for steal with upper extremity HA procedures. This knowledge can guide discussion of dialysis options and informed consent. If upper extremity HA procedures are undertaken in patients at risk, they should be closely monitored and early intervention applied if necessary.

Endovascular therapy in prevention and management of coronary-subclavian steal.

BACKGROUND: The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal. METHODS: The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed. RESULTS: Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%. CONCLUSION: PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.

[Subclavian-coronary steal syndrome following CABG--a case report]. / Zespól podkradania tetnicy podobojczykowej o nietypowym przebiegu anatomicznym.

A case of 47-year-old man with occlusion of the subclavian artery occurring few months after CABG with the left internal mammary artery grafting is presented. The patient developed a subclavian-coronary steal syndrome with retrograde blood flow from the coronary circulation to the subclavian artery through the left internal mammary artery. Clinical presentation consisted of vertigo and recurrence of chest pain. The increasing frequency of this syndrome and the preoperative preventive methods such as pressure gradient measurement between the left and right upper limb are discussed.

Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary-subclavian steal syndrome.

A hemodynamic significant left subclavian artery stenosis or occlusion proximal to the origin of the left internal mammary artery (LIMA) can result in an impaired or reversed flow through the LIMA and the coronary artery to which it has been anastomosed. In this study, we report on our immediate and long-term follow-up results in 31 consecutive patients who underwent percutaneous transluminal coronary angioplasty of the left subclavian artery shortly before or after coronary artery bypass grafting with use of the LIMA.

Use of angioplasty in the prevention and treatment of coronary--subclavian steal syndrome.

PURPOSE: The coronary-subclavian artery steal (CSS) syndrome is caused by critical stenosis in the subclavian artery proximal to a bypass graft from the internal mammary artery (IMA) to the coronary artery. The stenosis results in retrograde flow in the IMA and steal from the coronary artery. PATIENTS AND METHODS: Percutaneous transluminal angioplasty (PTA) was performed in eight patients (five men, three women). In four patients (group 1), coronary ischemia had developed 0.5-70 months (mean, 31 months) after IMA-to-coronary artery bypass surgery. These four patients (mean age, 58 years; range, 44-68 years) underwent PTA of a single area of focal subclavian stenosis to treat CSS. In four other patients (group 2), atherosclerotic subclavian stenosis had developed proximal to a donor IMA before planned bypass surgery. These patients (mean age, 53 years; range, 50-57 years) underwent PTA of a single focal subclavian stenosis to prevent CSS. RESULTS: Group 1 patients were free of myocardial ischemia at follow-up (mean follow-up, 39.0 months; range, 14-101 months). Three of four patients in group 2 underwent coronary artery bypass grafting with the ipsilateral IMA following PTA of the subclavian stenosis; they were free of angina at follow-up (mean follow-up, 14 months; range, 10-18 months). CONCLUSION: PTA is a safe and efficacious short-term method for prevention and treatment of CSS syndrome.

The coronary-subclavian steal syndrome: report of a case and recommendations for prevention and management.

The coronary-subclavian steal syndrome involves the siphoning of blood from the myocardium through an internal mammary artery graft because of a proximal subclavian artery stenosis or occlusion, and results in myocardial ischemia. With the increased use of the internal mammary artery for myocardial revascularization, the potential exists for recurrence of angina pectoris in patients who have or in whom develops high-grade stenosis or occlusion of the subclavian artery, because of the coronary-subclavian steal syndrome. The coronary-subclavian steal syndrome can be prevented by the identification of patients with or at risk to develop subclavian artery occlusive disease. All patients undergoing cardiac catheterization prior to coronary artery bypass grafting in which use of the internal mammary artery is anticipated should be evaluated for the presence of upper extremity and cerebrovascular ischemia, the presence of cervical or supraclavicular bruits, and an upper extremity blood pressure differential of 20 mm Hg or greater. Patients with these findings or with evidence of diffuse atherosclerotic vascular disease should have brachiocephalic arteriography at the time of coronary arteriography to identify significant subclavian artery occlusive disease. When this is demonstrated, use of the internal mammary artery as a free graft instead of an in situ graft or use of saphenous vein grafts is indicated. Patients in whom recurrent angina develops following coronary artery bypass grafting that included an internal mammary artery graft should have coronary arteriography to evaluate the presence of coronary-subclavian steal syndrome, and brachiocephalic arteriography. Carotid-subclavian bypass grafting, probably best done with a prosthetic conduit, is the procedure of choice for management of the coronary-subclavian steal syndrome.

[Aberrant subclavian artery in infants. Division and reimplantation into the common carotid artery through cervicotomy (author's transl)]. / Artère sous-clavière rétro-oesophagienne du nourrisson. Section et réimplantation dans in carotide primitive par cervicotomie.

In infants, merely dividing an aberrant subclavian artery (ROSCA) through left-thoracotomy may result in severe cerebral circulatory disorders by vertebrobasilar arterial steal. The authors report on 3 cases where reimplantation of the ROSCA into the common carotid artery reproduced a normal brachiocephalic arterial trunk and resulted in normal revascularization. In 2 of these 3 cases, the ROSCA was approached through a right cervical incision, divided in the mediastinum, behind the oesophagus, and reimplanted by latero-lateral anastomosis into the right carotid artery. In the third case the same approach was preceded by left thoracotomy for easier division of the ROSCA close to the aorta. The three operations were uneventful and no complication occurred, except for transient and mild left hemiparesis without sequelae in one patient.

Aberrant right subclavian artery aneurysm.

Ten patients with aneurysm of an aberrant right subclavian artery have been previously reported. Dysphagia is not commonly part of the initial symptomatology, and the diagnosis is usually established by chest roentgenogram, esophagogram, and aortography. If operative intervention is planned, adequate preparation for bypass and thoracic aortic grafting should be made since the aneurysm may also involve the descending thoracic aorta at the site of origin of the aberrant subclavian artery. Since both ischemia of the involved arm and the subclavian steal syndrome may occur after division of the origin of the subclavian artery, resotration of arterial flow in the distal subclavian artery is preferred. An additional patient is reported in whom right subclavian-to-carotid artery anastomosis was used after the subclavian artery aneurysm was removed.