Figure 1. A) and B). Cine coronary arteriography showing reverse flow from the LIMA towards the left...

Figure 2. Thoracic digital subtraction angiography showing a left common carotid artery with a heav...

Figure 3. Digital subtraction angiography of neck vessels showing a left internal carotid artery wi...

Figure 4. A) Left subclavian artery angioplasty with balloon-expandable endovascular stent-graft. B)...

Figure 5. A) Left internal carotid artery angioplasty with self-expanding stent. B) Common carotid a...

Figure 6. Cine coronary arteriography image at the end of the procedure confirming the presence of p...

INTRODUCTION

Coronary artery disease is one of the most common entities across the world. At times, it can be associated with carotid artery and other territories disease (1). Although the management of coronary artery disease can be percutaneous [percutaneous transluminal angioplasty (PTA)] or surgical [myocardial revascularization surgery (MRS)] the remaining vascular territories should be taken into consideration too for a comprehensive approach of patients with concomitant peripheral and central vascular disease. If not, different complications can occur, being one of them the coronary subclavian steal syndrome (2,3).

Coronary subclavian steal syndrome (CSSS) is a rare condition. It is due to the occlusion or severe stenosis of the subclavian artery, anterior and proximal to the origin of the vertebral artery (4,5). It affects the left subclavian artery in 90% of the cases and the right subclavian artery in 10% of the cases. The prevalence reported is between 0.6% and 6.4% (6). It responds well to percutaneous treatment, either with a balloon or endovascular implantation (stent).

In this article we present the case of a coronary subclavian steal syndrome followed by its percutaneous resolution.

OBJECTIVES

The objective of this study was to present a case report and a bibliographic review of the coronary subclavian steal syndrome

CLINICAL CASE

This is the case of 64-year-old woman with the following cardiovascular risk factors: arterial hypertension (AHT), dyslipidemia (DLP), and smoking; her cardiovascular clinical history revealed coronary artery disease due to severe lesions in the left main coronary artery (LMCA) and left anterior descending coronary artery (LAD) at ostial and mid-1/3rd level, and right coronary artery (RCA), accompanied by asymptomatic carotid artery disease. Due to the patient’s clinical history, she was treated with MRS with 2 bypasses (left internal mammary artery [LIMA] bridge to the LAD and saphenous vein graft to the RCA). Six months later she was admitted to the coronary unit with signs of unstable angina pectoris associated with heart failure. The patient had a good clinical response to the early anti-ischemic and diuretic treatment administered. The physical examination revealed asymmetrical brachial pulses, and a 30 mmHg difference of blood pressure measured between both arms. The cine coronary arteriography (CCA) performed 48 hours later revealed the presence of retrograde flow from the LIMA towards the left subclavian artery (Figures 1 A and B). The patient’s study was completed with an angiography of the neck blood vessels that confirmed the left subclavian artery occlusion (Figure 2) and the presence of heavily calcified lesions of the common carotid artery (CCA) and left internal carotid artery (Figure 3). It was decided to administer percutaneous treatment through a 2-staged angioplasty of the lesions described. A 0.035 in hydrophilic guidewire was advanced via left humeral access (Radiofocus Guide Wire M, Terumo, Japan). Two balloons of 4 mm x 30 mm and 6 mm x 30 mm in length were used for predilatation purposes (PTA Balloons, Cordis, United States). The angioplasty was performed from the origin of the left subclavian artery using a 9 mm x 38 mm balloon-expandable PTFE vascular peripheral covered stent (Advanta V12 Balloon Expandable Covered Stent, Atrium Medical Corporation, United States) (Figures 4 A and B). After the initial procedure, the patient’s progression was good, and she was discharged 24 hours later on dual antiplatelet therapy (aspirin and clopidogrel) plus antihyperintensive and lipid-lowering drugs. At a second stage, and since the patient showed signs of homolateral facial paralysis, a left common carotid artery angioplasty was scheduled using a 8 mm x 38 mm balloon-expandable PTFE vascular peripheral covered stent for the CCA (Advanta V12 Balloon Expandable Covered Stent, Atrium Medical Corporation, United States) and a left internal carotid artery angioplasty using a 7 mm x 30 mm self-expanding stent (Carotid Wallstent, Boston Scientific, United States) (Figures 5 A and B). A cerebral protection device was used to perform this procedure. The decision to choose the balloon-expandable PTFE covered stent to treat the left subclavian artery occlusion at a 1st stage and the left common carotid artery lesion at a 2nd stage was due to the fact that both arteries were heavily calcified, in aorto-ostial location, and with risk of dissection. A stent with enough radial strength was used for the proper expansion of the device and higher precision during implantation. Also, making sure that the origin of major blood vessels was not close by so they could be occluded by the stent (the left vertebral artery was already occluded and there was enough distance at the LIMA origin—subclavian PTA—and left carotid bifurcation—left common carotid artery PTA—to anchor the stents without compromising these vessels (7-10). The control cine coronary arteriography performed confirmed the correct antegrade flow of coronary arteries (Figure 6). The patient remained asymptomatic for angina pectoris, dyspnea or similar symptoms at the 6-month follow-up. The Doppler echocardiography of the neck vessels revealed normofunctioning stents with proper implant position and in-stent preserved velocity.

DISCUSSION

Patients with coronary artery disease often have lesions in other vascular territories. Preoperative studies are essential for a correct diagnosis, to omit concomitant conditions, and avoid complications (11). Cua et al. propose an algorithm that can be used in this group of patients (12).

The coronary subclavian steal syndrome was first described by Hargola and Valle more than 30 years ago (1974) (13). It is due to the presence of subclavian artery stenosis before the origin of the vertebral artery, which generates the retrograde flow from the ipsilateral vertebral artery (14-16). The presence of reverse flow in the left mammary artery when the contrast agent is injected into the left coronary artery is a definitive angiographic sign of coronary subclavian steal syndrome (17). The etiology of this rare entity (0.6% to 6.4%) (6) is atherosclerosis, vasculitis, temporal arteritis, and embryonic changes of the aortic arch (18,19) The clinical signs are cardiovascular symptoms (asymmetric pulses and AHT between both upper limbs, myocardial ischemia), neurological symptoms (in 5%, such as vertigo, ataxia, dysarthria, syncope, and binocular vision dysfunction) (20) and claudication of the diseased limb. A large number of these patients remain asymptomatic (21). There are different kinds of subclavian steal: type 1 (subclavian artery or braquiocephalic trunk proximal stenosis); type 2 (subclavian artery severe proximal stenosis); type 3 (vertebral artery antegrade flow), and type 4 (subclavian artery antegrade flow). Regarding their severity, they can be categorized into 3 groups: group I (pre-subclavian steal): reduction of vertebral antegrade flow; group II (intermittent/partial/latent): alternate flow – antegrade flow in diastole and retrograde in systole; group III (permanent/ advanced): permanent retrograde flow (6).

Diagnosis requires high clinical suspicion. As a matter of fact, the coronary subclavian steal syndrome has been reported in noncardiac surgery patients with previous bypass surgery using the internal mammary artery (22). It should be performed through vascular Doppler echocardiography (the vertebral artery flow reversal is confirmed) (23) cine coronary arteriography, CCTA or angio-MRI guidance (24). Treatment consists of balloon angioplasty and endovascular stent-graft into the occlusion site (25,26).

Traditionally, the surgical approach with prostheses or autologous grafts has been the treatment of choice for this type of patients. It consists of a carotid-subclavian or subclavian-subclavian bypass technique. Today, the development and progression of endoluminal procedures and the advances made with new materials (catheters, prostheses, etc.) facilitate the use of minimally invasive therapeutic alternatives. Also, they allow us to treat concomitant lesions simultaneously. Angle et al. reported a series of 21 patients with a 9.5% rate of major complications associated with this type of procedures.27 On the other hand, in a comparative study, Abu Rahma et al. concluded that the effects derived from surgical treatment remain in the long-term; however, the percutaneous approach is still the best option for patients at high surgical risk (28).

The case presented is a clear example of the complexity of patients with concomitant vascular lesions. We should mention that a complete preoperative study is essential to avoid overlooking the presence of stenosis in other arterial territories. Although this condition is rare, its high suspicion and early treatment avoid further complications.

CONCLUSION

The coronary subclavian steal syndrome is a rare entity that can cause myocardial ischemia in patients previously treated for this condition. Neurological symptoms can be associated too. Complete preoperative studies are required to prevent it and high clinical suspicion to diagnose it. Early percutaneous treatment with endovascular stent-grafts resolves it safely and effectively.

Conflicts of interest: None reported.

Funding: None reported.

Informed consent: All patients signed their informed consent forms before participating in the study gaving us authorization to use and publish their data.

1. Takach TJ, Reul GJ, Duncan JM, et al. Concomitant brachio-cephalic and coronary artery disease: outcome and decision analysis. Ann Thorac Surg 2005;80:564 56-9.

2. Olsen KG, Lund C. Subclavian steal syndrome.Tidsskr Nor Laegeforen. 2006;126(24):3259-3262.

3. Lak HM, Shah R, Verma BR, et al. Coronary Subclavian Steal Syndrome: A Contemporary Review.Cardiology. 2020;145(9):601-607.

4. Kliewer MA, Hertzberg BS, Kim DH, et al. Vertebral artery Doppler waveform changes indicating subclavian steal physiology. Am J Roentgenol, 2000; 174:815-819.

5. Tahmasebpour HR, Buckley AR, Cooperberg PL, Fix CH. Sonographic examination of the carotid arteries.Radiographics. 2005;25(6):1561-1575.

6. Osiro S, Zurada A, Gielecki J, et al. A review of subclavian steal syndrome with clinical correlation.Med Sci Monit. 2012;18(5):RA57-63.

7. Alaraj A, Wallace A, Amin-Hanjani S, et al. Endovascular implantation of covered stents in the extracranial carotid and vertebral arteries: Case series and review of the litera- ture. Surg Neurol Int. 2011;2:67.

8. Hoppe H, Barnwell SL, Nesbit GM, et al. Stent-grafts in the treatment of emergent or urgent carotid artery disease: review of 25 cases. J Vasc Interv Radiol. 2008;19:31-41.

9. Layton KF, Kim YW, Hise JH. Use of covered stent grafts in the extracranial carotid artery: Report of three patients with follow-up between 8 and 42 months. AJNR Am J Neuroradiol. 2004;25:1760-1763.

10. Saket RR, Razavi MK, Sze DY, Frisoli JK, Kee ST, Dake MD. Stent-graft treatment of extracranial carotid and vertebral arterial lesions. J Vasc Interv Radiol. 2004;15:1151-1156.

11. Waduud MA, Giannoudi M, Drozd M, et al. Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?Oxf Med Case Reports. 2018;2018(12):omy102.

12. Cua B, Mamdani N, Halpin D, et al. Review of coronary subclavian steal syndrome.J Cardiol. 2017;70(5):432-437.

13. Hargola PT, Valle M. The importance of aortic arch or subclavian an- giography before coronary reconstruction. Chest 1974; 66: 436-438.

14. Potter BJ, Pinto DS. Subclavian steal syndrome. Circulation. 2014;129(22):2320-2323.

15. Moccetti F, Brinkert M, Wolfrum M, et al. Coronary subclavian steal syndrome.Eur Heart J. 2020;41(13):1345.

16. Fonseka N, Dunn J, Andrikopoulou E, et al. Coronary subclavian steal syndrome.Am J Med. 2014;127(8):e11-12.

17. Álvarez J, Urda T, Mancha I, et al. Angina caused by coronary-subclavian steal in patients with coronary artery bypass with internal mammary artery. Rev Esp Cardiol 1998;51:772-775.

18. Antón Vázquez V, Armario García P, García Sánchez SM, et al. Subclavian steal syndrome: A forgotten aetiology of acute cerebral ischaemia.Neurologia. 2020;35(1):65-67.

19. Kargiotis O, Siahos S, Safouris A, et al. Subclavian Steal Syndrome with or without Arterial Stenosis: A Review.J Neuroimaging. 2016;26(5):473-480.

20. Shadman R, Criqui MH, Bundens WP, et al. Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases.J Am Coll Cardiol. 2004;44(3):618-623.

21. Labropoulos N, Nandivada P, Bekelis K. Prevalence and impact of the subclavian steal syndrome. Ann Surg. 2010;252(1):166-170.

22. Lobato EB, Kern KB, Bauder-Heit J, et al. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery.J Cardiothorac Vasc Anesth. 2001;15(6):689-92.

23. Harper C, Cardullo PA, Weyman AK, et al. Transcranial Doppler ultrasonography of the basilar artery in patients with retrograde vertebral artery flow.J Vasc Surg. 2008;48(4):859-864.

24. Toprak C, Yesin M, Mustafa Tabakci M, et al. Coronary Subclavian Steal Syndrome Evaluated with Multimodality Imaging.. Intern Med. 2015;54(21):2717-2720.

25. Usmanij EA, Senden PJ, Meiss L, et al. Myocardial ischaemia due to subclavian stenosis after coronary artery bypass graft: a case report.Eur Heart J Case Rep. 2018;2(2):yty069.
Che W, Dong H, Jiang X, et al. Subclavian artery stenting for coronary-subclavian steal syndrome.Catheter Cardiovasc Interv. 2017;89(S1):601-608.

26. Angle JF, Matsumoto AH, McGraw JK, et al. Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary-coronary bypass grafts: clinical experience and long-term follow-up.Vasc Endovascular Surg. 2003;37(2):89-97.

27. AbuRahma AF, Bates MC, Stone PA, et al. Angioplasty and stenting versus carotid-subclavian bypass for the treatment of isolated subclavian artery disease.J Endovasc Ther. 2007;14(5):698-704.

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