Prevalência de estenose da artéria subclávia em pacientes candidatos a cirurgia de revascularização do miocárdio: registro multicêntrico

Abstract

Prevalence of Stenosis of the Left Subclavian Artery in CABG Candidates: A Multicenter Registry Background: Approximately 90% of the patients submitted to coronary artery bypass graft surgery (CABG) receive a left internal thoracic artery (LITA) graft. Stenosis of the left subclavian artery can result in graft failure due to restricted coronary flow. The prevalence of stenosis of the left subclavian artery in patients with severe coronary atherosclerosis, deemed candidates to CABG, is not known. Objective: To assess the prevalence of stenosis of left subclavian artery in CABG candidates, as well as the diagnostic effectiveness of clinical evaluation. Methods: In a multicenter registry, selective angiography of the left subclavian artery was carried out in patients considered candidates to CABG during coronary cineangiography. Stenoses ≥ 50% proximal to the origin of the LITA were considered significant. Results: A total of 205 patients were included. Significant stenosis of the left subclavian artery was observed in 16 (7.8%) patients. Noninvasive differential arterial blood pressure measurement ≥ 10 mmHg between both arms showed low sensitivity (37.5%) and low positive predictive value (13.3%) for stenosis identification. No clinical predictors of significant stenosis were identified by univariate analysis. Conclusion: Stenosis of the left subclavian artery is not uncommon in CABG candidates. Noninvasive blood pressure gradient between both arms has low diagnostic accuracy. Therefore, in patients candidates to CABG, selective angiography of the left subclavian artery should be considered, because of the risk of reduced flow and coronary-subclavian steal syndrome in patients with non-diagnosed stenosis of the subclavian artery who receive a LITA graft.

Síndrome do roubo coronário-subclávio: relato de caso e revisão da literatura

“…Since the 1990s, percutaneous transluminal angioplasty is considered to be an effective method to treat for LSA stenosis 9 . Followed by the stent placement, the technique provides more anatomical and physiological results when compared to open surgery 7,12 , and it associated with low morbidity, zero mortality and short hospital stay 2,3,7 . The short term technical success is >90% 3 and five-year patency rates higher than 90% 2,3 have been reported.…”

“…Besides, when the stenosis is too close to the origin of the vertebral artery, the stent may occlude it 14 . Postangioplasty thrombosis is rare 2 ; however, long term in-stent stenosis was described as frequent by Schilliner et al, reaching 40.7% in five years [14][15][16] . Even then, the effectiveness of angioplasty with stent and open surgery is comparable 3 , with less complications in the angioplasty group, which leads to the conclusion that this should be considered as the primary choice of therapy 3,9 .…”

“…In cases of urgent MR with known LSA stenosis, cardiac surgery can be combined with the carotid-subclavian bypass 14 , or the right internal thoracic artery can be used to supply the coronary artery 2 . Angioplasty is the method of choice 2 on elective patients and those with LSA stenosis.…”

“…Thus, patients that are referred to myocardial revascularization (MR) usually have more severe coronary disease, frequently associated with atherosclerosis in other vascular territories 2 . The phenomenon of coronary-subclavian steal is defined as reverse blood flow in a coronary artery through an internal mammary artery graft (IMAG), towards the distal subclavian artery, and it happens in patients with severe stenosis or total occlusion of the proximal portion of the latter 1 .…”

“…The phenomenon of coronary-subclavian steal is defined as reverse blood flow in a coronary artery through an internal mammary artery graft (IMAG), towards the distal subclavian artery, and it happens in patients with severe stenosis or total occlusion of the proximal portion of the latter 1 . Despite being rare 2 , its morbidity is significant, with possible complications 3 that can lead to the coronary-subclavian steal syndrome (CSSS). It should be in patients after MR using the internal mammary artery graft as bypass, who develop recurrent chest pain, especially when triggered by physical effort 2 .…”