Aorto coronary subclavian steal - An interesting case report - MedIND

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Feb 27, 2007 - Department of Cardiac Surgery and Cardiac Anaesthesia, Manipal Heart Foundation. Airport Road, Bangalore. Address for correspondence:.

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Gowda et al 31 Coronary subclavian steal

Aorto coronary subclavian steal - An interesting case report Nagaraja Gowda, MD, Joseph Xavier, M.Ch., Sameer Rao, M.Ch., Murali Krishna, M.Ch. Department of Cardiac Surgery and Cardiac Anaesthesia, Manipal Heart Foundation Airport Road, Bangalore Abstract A patient who underwent coronary artery bypass grafting presented with severe left ventricle dysfunction. Coronary angiogram revealed coronary to subclavian steal with origin stenosis of left subclavian artery. (Ind J Thorac Cardiovasc Surg, 2007; 23: 31-33) Key words: Coronary artery bypass grafting, Stenosis, Echocardigraphy Introduction Coronary artery to subclavian steal with proximal subclavian artery stenosis is a well-documented entity. We present a unique case of Aorto-coronary - subclavian steal where both left internal mammary artery (LIMA) and reversed saphenous vein graft (RSVG) have been used to graft the left anterior descending (LAD) in its proximal and distal segment respectively. Case report A 63-year-old male patient had undergone coronary artery bypass grafting (CABG) in 1998 elsewhere, details of which were not available. He presented with easy fatigability and pedal edema of 2-3 months duration. There were no risk factors of diabetes, hypertension or smoking. On examination, pulse rate was 80/min, BP 130/80 mmHg in both upper limbs. On auscultation a pansystolic murmur Gr-3/6 was heard at apex. Respiratory system was clear. Biochemical and hematological parameters were within normal limits except for serum creatinine, which was 1.7 mg/dl. Electrocardiogram showed left bundle branch block and cardiomegaly on chest X-ray with cardiothoracic ratio (CTR) of 65%. Echocardiography showed left ventricle (LV) anterolateral segmental hypokinesia, dilated left atrium (LA) and left ventricle, moderate mitral Address for correspondence: Dr. Nagaraja Gowda Chief Consultant Cardiac Anaesthesiologist Manipal Heart Foundation Bangalore - 560 017. Fax: 91-80-25287741 E-mail: [email protected] © IJTCVS 097091342310307/35 Received - 17/05/06; Review Completed - 30/11/06; Accepted - 09/12/06.

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regurgitation (MR), severe pulmonary hypertension and severe left ventricle dysfunction with ejection fraction (EF) of 35%. The patient was on diuretics, amiodarone, statins and angiotensine converting enzyme inhibitors. Coronary angiogram (CAG) showed functioning grafts to left anterior descending, right coronary artery and obtuse marginal. Injection in the vein graft to left anterior descending showed well developed left internal mammary artery, retrograde filling of dye from left internal mammary artery (LIMA) into left subclavian artery and origin stenosis of left subclavian artery (figure 1a & 1b).

FOR SCAN

Fig. 1a. Retrograde filling of left internal mammary artery and left subclavian artery with origin stenosis following vein graft injection. LAD=left anterior descending, LIMA=left internal mammary artery

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Fig. 1b. LIMA and RSVG anastomosis to LAD.

Left subclavian artery angioplasty and stenting was planned under local anaesthesia which failed on repeated attempts both by antegrade and retrograde approaches. Left carotid to left subclavian artery bypass graft using 6 mm reinforced goretex graft was performed under general anaesthesia (GA). Due precautions were taken during GA considering his ventricular dysfunction status. Surgery was performed through left supra clavicular approach and a left carotid to left subclavian artery shunt was performed. Patient had an uneventful recovery. Patient’s symptoms & pedal edema disappeared. cardiothoracic ratio came down from 65% to 50%. Although there was no change in ejection fraction, the serum creatinine levels became normal. The moderate MR persists at 6 months follow-up, but patient is asymptomatic on medications. Discussion An increasing number of coronary subclavian steal (CSS) cases are being reported in literature. Recently Takach T J etal1 have exhaustively reviewed the coronary subclavian steal syndrome. The subclavian artery becomes functionally connected to the coronary circulation as a result of left internal mammary artery implantation during coronary artery bypass grafting. The coronary subclavian steal syndrome results from stenosis in the subclavian artery

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proximal to left internal mammary artery, compromising blood flow to myocardium. Coronary steal should be considered as a cause of recurrent symptoms in patients with previous coronary artery bypass grafting using left internal mammary artery. Our case is unique, probably the first of its kind being reported. During earlier coronary artery bypass grafting, the patient had received both reversed saphenous vein graft and left internal mammary artery grafts to left anterior descending artery. Since we do not have the prior medical records, we do not know the reason why the left internal mammary artery to left anterior descending graft was supplemented with a reversed saphenous vein graft distally. Also, we are not aware whether the patient had origin stenosis of the left subclavian artery prior to coronary artery bypass grafting. During coronary angiography injection into vein graft showed Aorta-reversed saphenous vein graftLAD, left internal mammary artery-Left subclavian steal with origin stenosis of the left subclavian artery. If the left subclavian artery stenosis is detected prior to coronary artery bypass grafting, vein grafts or free mammary graft are advised1. There are many causes of subclavian artery stenosis including atherosclerosis. Differential blood pressure recording in the upper limbs should be documented routinely in all patients awaiting coronary artery bypass grafting and arch vessel aortography should be performed in all patients likely to have coronary artery bypass grafting to rule out subclavian artery disease. Treatment of choice for subclavian stenosis is angioplasty and stenting. In our case since angioplasty was not successful, left carotid to subclavian bypass was performed. Acknowledgement We acknowledge the contribution of cardiology team of our institute. References 1. Takach JT, Reul GJ, Cooley DA, Duncan JM, Livesay J J, Ott DA, et al. Myocardial Thievery: The Coronary - Subclavian Steal Syndrome. Ann Thorac Surg. 2006; 81: 386–92.

Editor's Note The above article by Gowda et al is interesting for several reasons. (1) The entity subclavian steal is well known and documented. (2) The patient in this case report received both saphenous vein and internal mammary artery to the LAD. This is extremely unusual. It is not clear why

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the surgeon attached both the anterior descending artery. What is more astonishing is that both the grafts are open. It appears that antegrade flow from aorta has kept the vein graft open while retrograde flow through the internal mammary has been responsible for its

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patency. (3) The flow through these grafts has been significant enough to produce symptoms of a large shunt from aorta to left subclavian artery through the two grafts. (4) The authors must be congratulated for a fine demonstration of this unusual ‘steal’ phenomenon.

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