Endovascular therapy in prevention and management of coronary-subclavian steal

Alex Westerband, Julio A. Rodriguez, Venkatesh G. Ramaiah, Edward B. Diethrich, R. James Valentine

Research output: Contribution to journalArticle

57 Scopus citations

Abstract

Background: The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal. Methods: The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed. Results: Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%. Conclusion: PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.

Original languageEnglish (US)
Pages (from-to)699-703
Number of pages5
JournalJournal of vascular surgery
Volume38
Issue number4
DOIs
StatePublished - Oct 2003

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

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    Westerband, A., Rodriguez, J. A., Ramaiah, V. G., Diethrich, E. B., & James Valentine, R. (2003). Endovascular therapy in prevention and management of coronary-subclavian steal. Journal of vascular surgery, 38(4), 699-703. https://doi.org/10.1016/S0741-5214(03)00728-6