A Case of Recurrent Coronary Subclavian Steal Syndrome

Abstract

Coronary subclavian steal syndrome (CSSS) is one of the rare complications of coronary artery bypass graft surgery (CABG). This phenomenon is a potential complication after left internal mammary artery (LIMA) to left anterior descending artery (LAD) CABG. A proximal stenosis of the left subclavian artery (SA) could cause retrograde flow from LIMA to left SA, which characterizes the mechanism of CSSS. We describe a unique case of recurrent CSSS in a 64year-old female who presented with one month of exertional dyspnea and acute onset chest pain. She had an extensive coronary artery disease history with CABG 15 years prior to presentation and CSSS treated with left SA stent placement nine years later. She also underwent percutaneous intervention with stents placed in the saphenous vein graft. Although electrocardiogram, cardiac enzymes, and stress test did not show any evidence of acute ischemic changes, perfusion scan detected large areas of partially reversible ischemia. Cardiac catheterization was performed, which showed in-stent restenosis of the left SA and retrograde flow from the LIMA to the left SA indicative of recurrence of CSSS. Left SA arteriogram confirmed in-stent restenosis of the left SA, which was treated with balloon angioplasty and stent placement.

Atypical and rare cause of myocardial infarction: coronary subclavian steal syndrome (CSSS) treated by a carotid-subclavian bypass in a 71-year-old female patient

“…The SA stenosis may also lead to symptoms in the arm after exhaustive strain, including all symptoms of extremity ischemia [ 1 , 12 ], which were also present in our patient. Diagnostic procedures include bilateral blood pressure measurements (in case of physiological measurements also with careful provocative studies), as well as Doppler and duplex sonography of the SA [ 1 , 8 , 15 ]. To evaluate the vascular configuration as well as the presence of a stenosis or occlusion and to validate the patency of the arteries, a CT- or MR-A of the aortic arch and its branches might be performed [ 1 , 8 ].…”

“…It can prove the patency of the CABG and allows a simultaneous therapeutic intervention of the SA pathology [ 8 ]. Regarding the therapeutic options, interventional procedures like plain old balloon angioplasty (POBA), stent implantation [ 15 , 16 ], cutting balloon or laser [ 1 ] as well as various open surgical approaches like the performance of a CSB [ 1 , 12 ], an aorto-subclavian bypass [ 1 ], a carotid-axillary bypass [ 10 ], an axillo-axillary bypass [ 1 ], a subclavian-to-carotid transposition [ 17 ], a subclavian-subclavian bypass [ 17 , 18 ] or a re-insertion of the IMA-graft into the aorta [ 1 ] have been described. In case interventional therapy is not an option or a failed interventional therapy attempt, mainly due to severe calcifications of the SA, bypass surgery is required [ 1 , 19 ].…”