Successful stenting of total left subclavian artery occlusion post-coronary artery bypass graft surgery using dual left vertebral artery and left internal mammary artery protection

We report on a 68-year-old male patient (smoker, chronic obstructive pulmonary disease, diabetic for 25 years) who was admitted with acute pulmonary edema 5 months after undergoing coronary artery bypass grafting (left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior descending artery, and sequential saphenous vein graft to obtuse marginal artery). He had no cardiac enzyme leakage and his left ventricular ejection fraction was > 50% on 2-dimensional echocardiography. He proved to have total calcific left subclavian artery occlusion and retrograde flow in both his left internal mammary artery and his left vertebral artery upon left subclavian angiography performed through the left brachial approach. Angiographic vertebral and coronary-subclavian steals were both supported with clinical manifestations. The patient underwent successful stenting to his left subclavian artery using dual protection to his left vertebral artery with filter protection device and to his left internal mammary artery using simple balloon inflation at its mouth before and after each subclavian artery angioplasty step. Three months later, the patient was free from any cardiac or neurologic complaints.     

Claudication pain in the left arm of a coronary artery bypass graft patient using crutches: Coronary subclavian steal syndrome - a case report

A 77-year-old male former smoker with hypercholesterolemia and diabetes, who underwent coronary artery bypass graft surgery three years before admission and right carotid endarterectomy four years before admission, presented with recent-onset exertional chest pain. His medical history revealed that the chest pain was preceded by gradually worsening exertional claudication pain in his left arm when he was using crutches. The chest pain was similar to the pain he experienced before the coronary artery bypass graft surgery was performed. Coronary angiography and bypass graft imaging showed significant stenosis of the left subclavian artery proximal to the origin of the left internal mammary artery bypass, decreased flow in the left internal mammary artery with partial retrograde filling from the left anterior descending artery, and severe narrowing of the left vertebral artery with preserved centrifugal flow. Percutaneous stent implantation into the left subclavian artery was performed together with proximal balloon angioplasty of the left vertebral artery. The patient has been symptom free since the stent implantation.     

Angina pectoris caused by subclavian coronary steal

A 79-year-old white woman underwent coronary bypass graft surgery using a left internal mammary artery graft. The patient represented with chest pains 4 months later. A total occlusion of the left subclavian artery was documented with a coronary subclavian steal. The patient was treated with an axillo-axillary Gore-Tex graft. Pathophysiology and therapeutic options of the coronary subclavian steal are discussed.© 1993 Wlley-Liss, Inc     

A case of Coronary-Subclavian Steal Syndrome

Surgical bypass of left coronary artery disease using the internal mammary artery (IMA) as a conduit is standard practice. Adequate blood supply to the IMA is dependent on normal flow in the subclavian artery. Stenosis of the subclavian can impair coronary supply from the internal mammary artery. This may create a steal syndrome whereby the left arm may rob the coronary system of flow especially during arm exercise. In the present report a case of angina with left coronary system steal via an internal mammary graft due to atherosclerotic subclavian stenosis. Successful treatment of the anginal symptoms by native coronary stenting is described.     

Early postoperative occlusion of a left internal mammary artery bypass graft with subsequent restoration of patency.

Total occlusion of a left internal mammary artery (LIMA) bypass graft is a rare complication, and reversal of a documented occlusion has not been reported. This is a case of an early postoperative occlusion of a LIMA graft that was found to be patent 4 months later. A patient with three vessel disease (including a moderate lesion in the proximal left anterior descending artery and a severe lesion in its mid-portion) underwent coronary artery bypass grafting with a LIMA to the mid-left anterior descending artery (LAD) and saphenous vein grafts to the right coronary and left circumflex arteries. Coronary angiography 3 months after surgery revealed a totally occluded internal mammary artery and saphenous vein grafts. The patient then underwent a successful angioplasty of the more distal lesion in the LAD. She subsequently returned with recurrent angina. Repeat coronary angiography revealed rapid progression of the disease in the proximal LAD with the more distal angioplasty site being widely patent. Selective arteriography of the internal mammary artery at that time revealed a patent vessel. Thus, the internal mammary graft is a physiologically active conduit that is dependent on flow dynamics. Competitive flow through the nonobstructive native LAD in combination with impedance of flow through the internal mammary artery due to a severe lesion in the LAD distal to the anastomosis led to a functionally occluded LIMA. When the obstruction in the proximal LAD progressed and the distal obstruction was successfully angioplastied, the flow dynamics in the internal mammary improved, allowing for its dilatation and restoration of patency.(ABSTRACT TRUNCATED AT 250 WORDS)     

A uncommon cause of angina during upper limb exercise.

Subclavian artery stenosis or occlusion may be a cause of myocardial ischemia in patients treated using an internal mammary artery graft. Subclavian stenosis may cause myocardial ischemia during arm exercise by a coronary-subclavian steal phenomenon, with flow inversion in the graft from the coronary tree to the left subclavian artery. We here describe a case of a patient developing left subclavian occlusion after coronary artery bypass grafting with the left internal mammary artery. The lesion was successfully treated with a carotid-subclavian bypass. The article underscores the importance of an early diagnosis (possibly before bypass surgery) and discusses possible treatments. Percutaneous interventions with stent implantation appear the treatment of choice, but surgery has an important role in case of total occlusion.     

Evaluation of coronary subclavian steal syndrome using sestamibi imaging and duplex scanning with observed vertebral subclavian steal

Coronary subclavian steal is defined as retrograde blood flow from the myocardium through the internal mammary artery graft, secondary to a proximal subclavian artery stenosis. The incidence of this syndrome in patients undergoing internal mammary artery grafts for coronary artery bypass is estimated to be 0.44%. Angiography remains the definitive diagnostic test for confirming this condition. We describe a noninvasive method for evaluating coronary subclavian steal syndrome in a 57-year-old man, with a 50-55% subclavian stenosis confirmed by angiography. Noninvasive evaluation using duplex scanning demonstrated normal vertebral artery blood flow. Technetium 99m-sestamibi (99mTc) imaging confirmed a fixed anterolateral defect. When left-arm isometric exercise was employed, retrograde vertebral artery blood flow was observed by Doppler imaging. A repeat 99mTc-sestamibi study documented an increase in tracer distribution in the anterolateral defect confirming reperfusion of the myocardium through the left internal mammary artery graft. The use of duplex scanning and 99mTc-sestamibi may serve as an adjunct in evaluating coronary subclavian steal syndrome as well as documenting transient vertebral subclavian steal in this patient population.     

Early postoperative occlusion of a left internal mammary artery bypass graft with subsequent restoration of patency

Total occlusion of a left internal mammary artery (LIMA) bypass graft is a rare complication, and reversal of a documented occlusion has not been reported. This is a case of an early postoperative occlusion of a LIMA graft that was found to be patent 4 months later. A patient with three vessel disease (including a moderate lesion in the proximal left anterior descending artery and a severe lesion in its mid-portion) underwent coronary artery bypass grafting with a LIMA to the mid-left anterior descending artery (LAD) and saphenous vein grafts to the right coronary and left circumflex arteries. Coronary angiography 3 months after surgery revealed a totally occluded internal mammary artery and saphenous vein grafts. The patient then underwent a successful angioplasty of the more distal lesion in the LAD. She subsequently returned with recurrent angina. Repeat coronary angiography revealed rapid progression of the disease in the proximal LAD with the more distal angioplasty site being widely patent. Selective arteriography of the internal mammary artery at that time revealed a patent vessel. Thus, the internal mammary graft is a physiologically active conduit that is dependent on flow dynamics. Competitive flow through the nonobstructive native LAD in combination with impedance of flow through the internal mammary artery due to a severe lesion in the LAD distal to the anastomosis led to a functionally occluded LIMA. When the obstruction in the proximal LAD progressed and the distal obstruction was successfully angioplastied, the flow dynamics in the internal mammary improved, allowing for its dilatation and restoration of patency. Therefore, an angiographically occluded internal mammary graft may be only functionally occluded and reversible even when the occlusion is demonstrated several days apart.     

ST-Segment elevation acute myocardial infarction due to severe hypotension and proximal left subclavian artery stenosis in a prior coronary artery bypass graft patient

Proximal subclavian artery stenosis may result in cardiac ischemia in coronary artery bypass graft patients with internal mammary grafts. We report a case of acute anterior myocardial infarction in such a patient who developed severe systemic hypotension. Symptoms and electrocardiographic changes resolved after proximal left subclavian artery stenting. Subclavian angiography should be considered in all prior coronary artery bypass graft patients with internal mammary grafts undergoing coronary angiography.     

Subclavian coronary steal syndrome: an obligatory common fate between subclavian artery,internal mammary graft and coronary circulation

The long-term patency of the left internal mammary artery (IMA) has made it the preferred conduit for myocardial revascularization. The proximal segment of the subclavian artery becomes functionally connected to the coronary circulation as a result of IMA implantation during coronary artery bypass surgery. The subclavian coronary steal syndrome results from stenosis in the left subclavian artery proximal to the IMA, compromising blood flow to the myocardium. We describe 7 patients, aged 55-75 years, 1.7-10.5 years after coronary bypass who presented with recurrent angina due to subclavian artery stenosis. The IMA graft was found open in each patient. A true steal mechanism was not demonstrated, casting doubt on the syndrome's traditional name. Angioplasty and stenting of the subclavian artery resulted in the immediate disappearance of angina and continuous benefit at a follow-up of 3-32 months. The subclavian coronary steal syndrome, although rare, is a severe condition readily treated by angioplasty and stenting.     

Subclavian-coronary steal syndrome following CABG--a case report

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.     

Subclavian steal syndrome in acute myocardial infarction masquerading as acute embolism to left upper extremity-a case report

Subclavian steal syndrome is an uncommon entity diagnosed with angiography after neurologic symptoms occur during activity with the upper extremity. Cardiac symptoms or silent ischemia have been described in patients who have undergone cardiac bypass using the ipsilateral internal mammary artery. Our patient presented with acute chest pain radiating to the left upper extremity and a diminished pulse. Angiography to rule out an acute embolus instead revealed subclavian artery occlusion. As atherosclerosis is the most common cause, the ipsilateral subclavian artery should be carefully evaluated, particularly in cardiac patients undergoing coronary angiography. Recognition of coexisting subclavian artery occlusion could prevent cardiac complications that may occur with use of the ipsilateral internal mammary artery during coronary artery bypass surgery.     

Prevalence of subclavian artery stenosis in patients with peripheral vascular disease

Internal mammary arteries (IMA) as conduits in coronary artery bypass grafting are superior to saphenous vein grafts. If there is subclavian artery stenosis (SAS) proximal to the IMA graft, impairment of flow to the IMA may occur. If the stenosis is severe, retrograde flow from the grafted coronary artery to the brachial artery may lead to angina. Following the identification of 2 cases of angina secondary to subclavian artery stenosis at their institution, the authors prospectively performed arch angiography in a cohort of patients with manifestations of peripheral vascular disease undergoing diagnostic coronary angiography to assess the prevalence of subclavian stenosis. Fifty-two patients were enrolled in the protocol, with 48 patients having technically acceptable studies. Of these 48, 41.6% had measurable stenosis of at least one of the brachiocephalic arteries, with 35% of patients with at least a 30% stenosis of the left subclavian artery and 18.7% with more than 50% stenosis. They conclude that patients with significant peripheral vascular disease undergoing coronary angiography who are potential candidates for revascularization may benefit from arch angiography as part of their initial evaluation.     

Relocation of the internal mammary artery graft in a case of coronary-subclavian steal

Reverse flow in the internal mammary artery coronary graft in the presence of subclavian stenosis is rare. We describe a 67-year-old man who 7 years after coronary artery surgery was admitted with left subclavian artery stenosis and retrograde flow in the pedicled left internal mammary artery graft. Subsequent redo triple coronary artery bypass grafts included regrafting the left internal mammary artery graft to a new vein conduit.     

Cardiogenic Shock After Arterial Y-Graft Coronary Bypass Surgery Secondary to Critical Stenoses of the Left Subclavian and Left Main Coronary Arteries

We present a case of a 62-year-old man who was in cardiogenic shock. He had a history of coronary artery bypass grafting 4 years previously, with left internal mammary radial artery Y-grafting to a left dominant coronary circulation. Critical stenoses of the left main coronary and left subclavian arteries were seen at angiography. An occluded abdominal aorta precluded the use of mechanical circulatory support. The patient underwent high-risk stenting of the left subclavian artery with a successful outcome. The case highlights the unresolved issue of screening for subclavian stenoses in patients being considered for revascularization with arterial Y-grafting.     

Collateralization of an occluded left internal mammary artery coronary bypass graft

The left internal mammary artery (LIMA) is frequently utilized in coronary artery bypass grafting (CABG); adequate visualization of the LIMA bypass graft during diagnostic angiography is critical for determination of myocardial blood supply. We present a novel case of angiography via a left transradial approach demonstrating an occluded LIMA coronary bypass graft with antegrade flow maintained via a collateral branch from the ipsilateral thyrocervical trunk. Given the prevalence of LIMA use in CABG, it is critical to be aware of unusual configurations, including collateralization of a proximally occluded LIMA graft as described in this report.     

Bilateral selective internal mammary artery angiography via right radial approach: clinical experience with newly designed Yumiko catheter.

The radial artery has been increasingly used as a primary access site for coronary angiography and intervention. But the technique for internal mammary artery (IMA) visualization via the right radial artery has not been well described. Therefore, the study was conducted to investigate the feasibility, safety, and adequacy of selective bilateral IMA angiography via the right radial artery using the recently developed Yumiko catheter. From November 1999 to October 2000, both IMA angiographies were undertaken immediately following the diagnostic coronary angiogram taken from right transradial approach in 114 patients. IMA angiography was successfully obtained in 99% (113/114) patients. For left IMA angiography, 73 (64%), 28 (25%), and 12 (11%) imagings were obtained in a selective, a semiselective, and a nonselective way, respectively. After initial periods of 33 left-IMA-only imaging, right IMA angiography was obtained in 81 patients (phase 2). Selective right IMA imaging was done in 73 (90%), semiselective in 6, and nonselective in 2 patients. The reasons for failure of selective or semiselective visualization were severe vascular tortuosity, far distal anatomical origin of left IMA and ulcerative plaque, or acutely angled left subclavian artery. The feasibility and safety of selective and semiselective bilateral IMA angiography were demonstrated using a 5 Fr Yumiko catheter from the right radial approach. Cathet Cardiovasc Intervent 2001;54:19-24.     

Coronary steal due to bilateral internal mammary artery--pulmonary artery fistulas: a rare cause of chest pain after coronary artery bypass grafting.

A 54-year-old man with a history of coronary artery bypass grafting (CABG) presented with chest pain and was found to have non-ST-segment elevation myocardial infarction. Left heart catheterization with coronary angiography demonstrated 100% occlusion of the right internal mammary artery (IMA) to the right coronary artery graft in its midsegment and a patent left IMA to the left anterior descending graft. An unusually large extensive fistulous collateral formation was observed between the right IMA and the left IMA to the pulmonary arterial system, causing left to right shunting. His angina was attributed to substantial coronary steal caused by the shunt. The patient refused any further intervention or surgery and opted for medical treatment. As a complication of CABG, IMA to pulmonary artery (PA) fistulas are rare. Thus far, more than 20 cases have been reported; most have been unilateral. This is the second reported case to date of bilateral IMA-PA fistula formation after CABG. An IMA-PA fistula should be considered in the differential diagnosis of patients presenting with chest pain after CABG and can be diagnosed by selective angiography of IMA grafts.     

Balloon expandable stent implantation after latrogenic arterial dissection of the left subclavian artery

A patient undergoing attempted angioplasty of a left internal mammary artery graft to left anterior descending coronary artery developed an iatrogenic dissection of the left subclavian artery, with symptoms of left arm claudication. A balloon expandable stent was inserted with an excellent angiopgraphic result. The patient has remained free of symtoms or signs of decreased arm flow, with a patent subclavian artery demonstrate on angiography 8 months later. The excellent early-to-moderate term clinical and angiographic results support the efficacy of this technical approach. © 1995 Wiley-Liss, Inc.     

Percutaneous transluminal angioplasty of proximal subclavian artery stenosis after left internal mammary to left anterior descending artery bypass surgery.

A patient is described who underwent percutaneous transluminal angioplasty, through a brachial approach, of a high grade stenosis at the proximal portion of the left subclavian artery 1.5 years after coronary artery bypass grafting including left internal mammary to left anterior descending artery anastomosis. Symptoms of class IV angina, vertebrobasilar insufficiency and occupational arm claudication that developed after bypass surgery were promptly relieved after balloon dilation. Percutaneous transluminal angioplasty of the subclavian artery can be performed safely and provides an alternative to carotid-subclavian or axillary-axillary bypass surgery for treatment of internal mammary artery graft malfunction.