# Coronary-Subclavian Steal Syndrome:  A Rare  Cause of  Angina Pectoris

Authors: D. P. Papadopoulos; V. Votteas
Journal: Scholarly Research Exchange
 (2008)

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## Abstract

A 70-year-old woman with recurred episodes of angina pectoris was
admitted to our hospital for evaluation. After coronary
angiography, a coronary-subclavian steal syndrome was reveled. A
PICA in subclavian artery was performed  to treat  this patient.


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## Body

## 1. Introduction

We report a rare cause  of recurrent
chest pain after coronary artery bypass surgery. A patient with subclavian
steal syndrome, treated effectively with percutaneous balloon angioplasty, is
described.


## 2. Case Report

A 70-year-old woman, with recurrent
angina six years after coronary artery by pass grafting was referred to our
department for evaluation. The patient with a history of hypertension, type 2
diabetes, and hypercholesterolemia, six years prior to evaluation, had
undergone coronary artery bypass surgery with left internal mammary artery
(LIMA) anastomosed to the left anterior descending (LAD) artery and saphenous
vein graft to the obtuse marginal branch artery of the circumflex artery. She
had remained symptoms free until 3 weeks ago when she started having prolonged
episodes of chest discomfort accompanied with exertional dyspnea. Remarkably
she experienced chest pain on exercising the left arm. Examination revealed a
significant difference of blood pressure between the arms (right 102/59, left
80/40). The patient underwent an exercise test that was positive for ischemia
in the posterolateral wall of the left ventricle. Coronary angiography
demonstrated severe left main stenosis and patent vein graft to the left
circumflex marginal branch. The left internal mammary artery was opacified
retrogradelly through the LAD. Aortic arch angiography documented total
occlusion of the left subclavian artery proximal to  the origin of the LIMA
(Figure1). When digital angiography
highlighted exactly the relationship of the left subclavian occlusion in regard
to the rest of the vessels of the aortic arch, the patient was referred to be treated preferentially with
percutaneous  angioplasty.Figure 1
Arch aortic angiography
showing the total occlusion of the left subclavian artery.


## 3. Discussion

Coronary-subclavian steal syndrome (CSSS)
was first reported in 1974 [1]. The incidence
of CSSS has  increased the last
years from 0.5% [2, 3] to
3.4% [4] in patients who undergo CABG using the LIMA
as a conduit bypass
graft. Ischemic symptoms can present immediately following CABG surgery or up
to 7 years later [2, 3]. Symptoms of CSSS may include angina, vertigo, and
syncope with left arm exercising. Patients who remain asymptomatic despite
angiographic evidence of CSSS are at increased risk of sudden death.
Examination may reveal differences in blood pressure between the arms. This
finding may be suggestive of subclavian stenosis but a normal blood pressure does not
exclude the problem. The mechanism of CSSS consists of a stenosis in the
proximal part of the subclavian artery resulting in reversal of flow in LIMA
graft and subsequent
ischemia in the territory it supplies. The subclavian artery stenosis produces a
negative pressure gradient between subclavian and LIMA
graft. Subsequent retrograde filling of
the subclavian artery via the LIMA
graft causes the subclavian to “steal” blood from the coronary circulation.Both operative and radiological techniques
can be used to restore adequate flow to the subclavian artery with relief of
angina [5]. Percutaneous
treatment  of subclavian artery stenosis was first
described  by Bachman and Kim  in
[6]. It is less invasive, has lower
complication rates, and has a shorter hospital stay than surgical treatment.
Both the immediate and the long-term results after percutaneous balloon
angioplastic are excellent [7, 8], especially with the use of stents
[9].
Although surgical treatment remains feasible, percutaneous revascularization is now the treatment of choice in the
management of subclavian steal syndrome [10].



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