Atrial fibrillation as a contributing factor in the diagnostic algorithm for coronary subclavian steal syndrome and cardiac tamponade following coronary artery bypass graft surgery: a case study

Coronary subclavian steal syndrome (CSSS) is a complication of coronary artery bypass graft (CABG) surgery in patients with coexistent significant subclavian artery stenosis (SAS). It is characterized by a retrograde blood flow through the left internal mammary artery graft from the coronary to subclavian circulation, leading to myocardial ischemia. Current screening for CSSS includes bilateral blood pressure measurement for the detection of a significant inter-arm blood pressure difference. However, the commonly used automated sphygmomanometers have limited accuracy in patients with atrial fibrillation. Consequently, these patients are often underdiagnosed. We present a case of a 73-year-old man with a medical history of atrial fibrillation, peripheral artery disease, and CABG surgery four months before the current event, who came to the emergency department due to progressive dyspnea. The initial diagnostic management showed a large circulatory pericardial effusion, so the patient was admitted to the coronary care unit and underwent pericardial drainage. In the following days, due to a sudden high increase in cardiac troponin, the patient underwent an urgent coronary angiography, which revealed severe left SAS with functional CABG, indicating the occurrence of CSSS. Percutaneous transluminal angioplasty was then performed with an optimal angiographic result. The patient was discharged in good condition with adequate medicament therapy and instructions. This case report highlights atrial fibrillation as a contributing factor for the diagnosis of CSSS and pericardial tamponade after CABG surgery. Furthermore, we suggest a diagnostic approach that can reduce the incidence of both these severe complications.

Coronary subclavian steal syndrome (CSSS) occurs in the presence of subclavian artery stenosis (SAS) or occlusion and represents a reversal of blood flow in the left internal mammary artery (LIMA) bypass graft, which leads to coronary ischemia. It presents as a complication in 2.5–4.5% of patients undergoing coronary artery bypass graft (CABG) surgery. The prevalence is even higher in patients with peripheral artery disease (PAD), who have a 5-fold increased risk of SAS (1,2). It commonly presents as stable angina triggered by left upper extremity activity, but can also manifest as an acute coronary syndrome, acute heart failure, ventricular arrhythmia, or even sudden cardiac death (3). Digital subtraction angiography, the current gold standard in the imaging of CSSS, has lately been increasingly replaced by other diagnostic tools, such as duplex ultrasound (DUS), computed tomography angiography (CTA), and magnetic resonance angiography. The current guidelines recommend the endovascular approach as the first-line treatment of CSSS and vascular surgery as the second option (4).