Coronary steal: how many thieves are out there?

Abstract

The colorful term “coronary steal” arose in 1967 to parallel “subclavian steal” coined in an anonymous 1961 editorial. In both instances, the word “steal” described flow reversal in the setting of an interconnected but abnormal vascular network—in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Anomalous Arising of Right Coronary Artery from the Pulmonary Artery

“…The absence of collateral circulation between the right and left coronary artery lead to a very early manifestation of symptoms of dilated cardiomyopathy and heart failure, with the incidence of sudden death in 90% of cases [3,8,9,15]. It is caused by decrease of pulmonary arterial pressure and coronary vascular reserve decrease [16]. This manifestation occurs typically at 2-3 months of age [7].…”

“…The vascular resistance of the collateralized coronary circulation can lead to a balanced state with minimal shunting from the aorta to the truncus pulmonalis. On the other hand, this balance can be disturbed by changing the pressure ratios during exercise [16]. One-third to two-thirds of patients with ARCAPA are asymptomatic and have the best prognosis among all forms of anomalous arising of the coronary artery from the PA [4,14].…”

Coronary branch steal due to an anomalous single and diseased vessel

“…Coronary steal describes the end result of a variety of mechanisms that cause stress flow to fall below resting levels. 1 The most common scenario arises from a collateral-dependent chronic total occlusion (CTO) with a diseased donor vessel. While resting flow remains intact due to vasodilation of the CTO bed, pressure loss in the donor artery during hyperaemia leads to a drop in distal coronary pressure at the origin of the collaterals.…”

Fistulous communication between the left main coronary artery and the pulmonary artery as a cause of angina

“…The clinical symptoms are attributed to the “coronary steal phenomenon”, which can lead to symptoms such as angina or dyspnea even in the absence of stenosis [ 13 ]. The term “coronary steal” emerged in 1967 as a vivid description, drawing a parallel to the term “subclavian steal” introduced in an editorial in 1961 [ 14 , 15 ]. Both terms employed the concept of “steal” to depict flow reversal within an interconnected yet abnormal vascular network [ 15 ].…”

“…The term “coronary steal” emerged in 1967 as a vivid description, drawing a parallel to the term “subclavian steal” introduced in an editorial in 1961 [ 14 , 15 ]. Both terms employed the concept of “steal” to depict flow reversal within an interconnected yet abnormal vascular network [ 15 ]. The fistula between the LM and the PA establishes continuous flow throughout the cardiac cycle, with direction from the LM to the PA [ 2 ].…”