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[Coronary-subclavian steal syndrome]
A T Bäumer1, G Nickenig, D Moka
1Klinik III für Innere Medizin, Germany.
Insights
Recurrent angina after coronary artery bypass grafting (CABG) may indicate coronary-subclavian steal syndrome. This condition, characterized by arm blood pressure differences, is best treated with subclavian artery revascularization.
Area of Science:
- Cardiology
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) is a common treatment for coronary triple vessel disease.
- Recurrent angina after CABG can have various causes, including graft failure or new stenoses.
Observation:
- A patient with generalized atherosclerosis experienced recurrent angina triggered by left arm exercise 17 months post-CABG.
- Stress technetium scans revealed left ventricular ischemia during left upper limb exercise.
- Coronary angiography showed reverse flow in the internal mammary artery (IMA) graft and left subclavian artery blockage.
Findings:
- The patient presented with a coronary-subclavian steal syndrome.
- A significant pressure difference (>20 mmHg) between arms is typical for this syndrome.
- Reverse flow in the IMA graft suggests steal phenomenon.
Implications:
- Coronary-subclavian steal syndrome should be considered in post-CABG patients with recurrent angina, especially when symptoms are arm-exercise induced.
- Percutaneous transluminal revascularization of the subclavian artery is the preferred treatment.
- Early diagnosis and intervention can prevent further cardiac events.
History And Clinical Findings:
A-46-year-old woman with generalized atherosclerosis and coronary triple vessel disease was admitted with recurrent angina pectoris 17 months after primarily successful triple coronary artery bypass grafting (CABG). The symptoms were induced by exercise of the arms, e. g. carrying shopping bags in the left hand.
Investigations:
Stress technetium scans showed pronounced left ventricular ischemia of the anterior wall and apex during left upper limb exercise in comparison to bicycle exercise. The coronary angiography showed reverse flow in the internal mammary artery (IMA) graft to the left anterior descending artery (LAD), and aortography disclosed blockage of the proximal left subclavian artery.
Treatment And Course:
: The patient declined percutaneous transluminal interventions or surgical procedures of the left subclavian artery. Because of mild angina and the lack of neurological symptoms, she was discharged on optimal drug treatment.
Conclusion:
: Patients with recurrence of cardiac symptoms after CABG surgery and IMA graft may have a coronary-subclavian steal syndrome. Clinically, these patients present with arterial blood pressure differences between left and right arm of typically more than 20 mmHg. The therapy of choice are percutaneous transluminal revascularization procedures of the subclavian artery.