Coronary subclavian steal syndrome
Marc Sintek1, Edward Coverstone, Jasvindar Singh
1Washington University in St Louis School of Medicine - Cardiovascular division.
Insights
Coronary subclavian steal syndrome (CSSS) is a treatable cause of ischemia after bypass surgery. Percutaneous revascularization is the preferred treatment for CSSS, offering safe and effective symptom relief.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Medicine
Background:
- Coronary subclavian steal syndrome (CSSS) involves reversed blood flow in internal mammary artery grafts, causing myocardial ischemia.
- It is an uncommon yet treatable complication following coronary artery bypass grafting (CABG).
Observation:
- CSSS typically arises from subclavian artery stenosis, affecting 2.5-4.5% of CABG patients.
- Clinical presentations are varied, including myocardial infarction, unstable angina, and heart failure.
- Screening involves checking bilateral brachial blood pressures before CABG.
Findings:
- Both surgical and percutaneous revascularization effectively resolve CSSS symptoms with excellent long-term patency.
- Percutaneous revascularization is the recommended first-line therapy.
- It can be safely performed before CABG to prevent CSSS development.
Implications:
- Suspicion of CSSS is crucial in post-CABG patients with ischemic symptoms.
- Percutaneous revascularization provides a safe and effective treatment option for CSSS.
- Early intervention can prevent severe cardiac events.
Purpose Of Review:
Coronary subclavian steal syndrome (CSSS) is the reversal of blood flow in an internal mammary artery bypass graft that results in coronary ischemia. CSSS is an uncommon but treatable cause of coronary ischemia. In this review, we highlight the historical background and epidemiology of CSSS, common clinical presentations, diagnosis of CSSS and management strategies for relieving ischemia. We also present a case report to illustrate the complexity of CSSS and percutaneous management using current technology.
Recent Findings:
Most commonly, CSSS results from atherosclerotic stenosis of the subclavian artery and occurs in 2.5-4.5% of patients referred for coronary artery bypass grafting (CABG). All patients referred for CABG should have bilateral noninvasive brachial blood pressures checked to screen for the underlying subclavian stenosis. A review of 98 case reports with 128 patients demonstrated a diverse clinical presentation of CSSS, including acute myocardial infarction, unstable angina and acute systolic heart failure. Resolution of CSSS symptoms has been reported with both surgical and percutaneous revascularization. Long-term patency with either revascularization strategy is excellent. Percutaneous revascularization is largely considered the first-line therapy for CSSS and can be safely performed prior to CABG to prevent CSSS.
Summary:
CSSS should be suspected in patients presenting with angina, heart failure or myocardial infarction after CABG. Successful amelioration of CSSS symptoms can be safely and effectively performed via percutaneous revascularization.
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