Coronary‐subclavian steal syndrome, an easily overlooked entity in interventional cardiology

Roeck, Frederic De; Tijskens, Maxime; Segers, Vincent F.M.

doi:10.1002/ccd.28362

Cited by 11 publications

(6 citation statements)

References 20 publications

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“…This imaging modality has shown high sensitivity (90%) and specificity (96%) for the diagnosis of a luminal stenosis greater than 50%. 10 Nonetheless, CSSS can induce the entire clinical spectrum of ischaemic heart disease, ranging from progressive angina (particularly associated to left arm exertion) to acute coronary syndromes, 11 as is well represented in Patients 1 and 2, respectively. According to a case series, the most frequent clinical presentation was stable angina.…”

Section: Discussionmentioning

confidence: 99%

“…A difficult left SA catheterization with a pressure gradient >10 mmHg is another suggestive sign (Patient 2). 13 Left SA angiography remains the gold standard of diagnosis, 11 and it can be performed in the catheterization laboratory during coronary angiography. Myocardial perfusion scintigraphy to document myocardial ischaemia was performed in Patient 1.…”

Section: Discussionmentioning

confidence: 99%

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Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

Real

Vivas

Martínez

et al. 2021

European Heart Journal - Case Reports

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Background Coronary subclavian steal syndrome (CSSS) is an uncommon complication observed in patients after coronary artery bypass surgery with left internal mammary artery (LIMA) grafts. It is defined as coronary ischaemia due to reversal flow from the LIMA to the left subclavian artery (SA) when a proximal left SA stenosis is present. In practice, the entire clinical spectrum of ischaemic heart disease, ranging from asymptomatic patients to acute myocardial infarction, may be encountered. Case summary Three cases of CSSS recently detected at our hospital are being described. Two patients presented with an acute coronary syndrome, so diagnosis was suspected based on coronary angiography findings, as retrograde blood flow from LIMA to the distal SA was present. Myocardial ischaemia was documented by myocardial perfusion scintigraphy in one case. The third patient was asymptomatic and CSSS was suspected during physical examination and confirmed by computed tomography (CT). Endovascular intervention with balloon-expandable stent implantation of the stenotic SA was performed by vascular surgeons in all patients. No periprocedural complications occurred, and complete resolution of symptoms was achieved. Discussion In CSSS, subclavian angiography is the standard diagnostic test. However, other diagnostic techniques may be valuable to better clarify this challenging diagnosis. In the herein small series, the usefulness of a multimodality imaging approach including Doppler ultrasound, myocardial perfusion scintigraphy, and CT is well demonstrated. Furthermore, this study endorses the safety and utility of endovascular treatment in different clinical scenarios, including asymptomatic patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

Real

Vivas

Martínez

et al. 2021

European Heart Journal - Case Reports

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“…CSSS is a serious and potentially lethal complication with underestimated incidence, especially in some high-risk subgroups ( 2 ). Ever since it was first reported by Tyras and Barner ( 5 ), various clinical presentations of this syndrome resulting in severe outcomes have been described ( 1 , 3 ). For this reason, several author groups proposed diagnostic approaches to evaluate SAS and prevent this syndrome.…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

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confidence: 99%

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

Perčin¹,

Glavaš²,

Konja³

et al. 2021

Croat Med J

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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.

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“…CSSS is estimated to complicate between 0.2-6.8% of CABG operations [1] and is due to subclavian artery stenosis (SAS) or occlusion which has been reported to be present in up to 5.3% of patients undergoing CABG, and in 11.8% of those with a history of peripheral vascular disease (PVD) [2]. It typically presents after surgery with symptoms ranging from stable angina to acute coronary syndrome and even sudden cardiac death that may occur many months postoperatively usually following left arm exertion [3].…”

Section: Commentmentioning

confidence: 99%

Intra-operative Coronary Subclavian Steal Syndrome

Mann¹,

Tweed²,

Berman³

et al.

Authorea

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Coronary-subclavian steal syndrome (CSSS) describes the condition whereby haemodynamically significant proximal subclavian artery stenosis results in flow limitation or reversal within the left internal mammary artery (LIMA) graft, classically precipitated by upper limb exertion. We report an unusual presentation, where a patient developed pronounced ST-depression and haemodynamic instability immediately following weaning from bypass. The patient was subsequently found to have occlusion of their left subclavian artery. Despite its incidence, there are currently no recommendations for screening for subclavian artery stenosis. We propose a preoperative screening algorithm that may allow for intervention prior to CABG, enabling risk-free use of the LIMA.

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Coronary‐subclavian steal syndrome, an easily overlooked entity in interventional cardiology

Cited by 11 publications

References 20 publications

Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

Endovascular treatment of coronary subclavian steal syndrome: a case series highlighting the diagnostic usefulness of a multimodality imaging approach

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

Intra-operative Coronary Subclavian Steal Syndrome

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