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British Journal of Radiology (2004) 77, 441-444
© 2004 British Institute of Radiology
doi: 10.1259/bjr/32305979
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Case report

Coronary subclavian steal syndrome: non-invasive imaging and percutaneous repair

I A Wright, PhD, A D Laing, FRACR and T M Buckenham, FRCR, MBChB

Department of Radiology, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand


   Abstract
Top
 Abstract
Case report
 Discussion
 References
 
Although coronary subclavian steal syndrome (CSSS) is relatively uncommon, it is a well documented cause of graft failure in patients having undergone coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA). Here we report a case of CSSS induced by restenosis of a left subclavian artery (SCA) origin stent, identified by increased velocities within the stent and an abnormal ipsilateral vertebral artery (VA) waveform on Duplex ultrasound imaging. This was successfully treated percutaneously by re-stenting, resulting in restoration of normal SCA waveforms and velocities, and normalization of the ipsilateral VA waveform.


   Case report
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 Abstract
 Case report
Discussion
 References
 
A 66-year-old female ex-smoker with hypercholesterolaemia was admitted with fatigue, lethargy and shortness of breath on exertion which had gradually worsened over the preceding few months, and left arm pain on sustained movement. She had a history of right heart failure, tricuspid regurgitation, haemolytic anaemia, chronic atrial fibrillation and hyperthyroidism, and had previously undergone three mitral valve replacements (most recently 5 years prior) and coronary artery bypass grafting (CABG), coronary artery stenting (2 years prior) and left subclavian artery (SCA) stenting (1 year prior). The long saphenous vein and left internal mammary artery (LIMA) were used as conduits in the coronary artery bypass. Physical examination revealed a bruit over the left clavicle, and a difference in blood pressure between the right and left arm of 60 mmHg. Recent coronary angiography had shown retrograde flow in the LIMA graft on injection of the left coronary arteries. Duplex ultrasound demonstrated a 90% proximal left SCA stenosis, with velocities in excess of 3 m s–1 noted within the stent (Figure 1Go), and an abnormal Doppler waveform in the left vertebral artery (VA) (Figure 2Go). Arch angiography confirmed a 90% stenosis within the left SCA stent, and demonstrated antegrade VA flow and an absence of antegrade LIMA flow, the latter being confirmed on selective left SCA injection (Figure 3Go). Left common and internal carotid artery origin stenoses of 50% and 90%, respectively, were also identified, and the right VA was shown to be diffusely diseased. The SCA stenosis was successfully dilated and an 8 mm x 4 cm balloon expandable stent placed with no complications (Figure 4Go). Duplex ultrasound 24 h later demonstrated normal Doppler waveforms and velocities within the stent (Figure 5aGo), and conversion of the left VA waveform to a normal pattern (Figure 5bGo). The patient was subsequently discharged having also undergone several blood transfusions to manage her haemolytic anaemia. She was asymptomatic on review 2 months later, at which time follow-up Duplex ultrasound showed normal left VA and SCA waveforms and velocities.



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  		Figure 1. Duplex ultrasound image of the proximal left subclavian artery (SCA) prior to restenting; velocities of over 3 m s–1 are demonstrated within the stent.

 


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  		Figure 2. Corresponding Duplex ultrasound image of the left vertebral artery showing an abnormal waveform. Antegrade flow is present throughout the whole cardiac cycle but there is marked mid-systolic deceleration.

 


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  		Figure 3. Angiogram of the left subclavian artery and its branches showing a severe in-stent stenosis at the subclavian origin and an absence of antegrade internal mammary artery filling.

 


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  		Figure 4. Angiogram of the left subclavian artery and its branches showing successful dilatation of the subclavian stenosis, new stent placement and restoration of antegrade internal mammary artery flow.

 


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  		Figure 5. (a) Duplex ultrasound image of the proximal left subclavian artery (SCA) post stent placement, with normal waveform and velocities. (b) Duplex ultrasound image of the left vertebral artery (VA) displaying a normal antegrade waveform post subclavian artery stent placement.

 

   Discussion
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 Abstract
 Case report
 Discussion
References
 
A steal occurs when there is a pressure gradient between the donor and recipient arteries [1], as commonly seen in vertebral subclavian steal syndrome (VSSS). In coronary subclavian steal syndrome (CSSS), however, both the coronary artery (donor) and the SCA (recipient) are stenosed and therefore it is unlikely that a pressure gradient would exist. It would appear that myocardial ischaemia is likely to be a result of the haemodynamic disturbance caused by the functional coronary circulation which includes the proximal left SCA and its branches. The incidence of CSSS is less than 0.5% [2, 3]. It is caused by a significant SCA stenosis present at the time of CABG, or may occur post-CABG following the progression of SCA disease, as in this case.

The incidence of CSSS due to missed significant SCA disease is unclear, but Marques et al [4] report an incidence in patients referred for CABG of significant SCA stenosis of 0.7%. In order to detect the presence of a SCA stenosis prior to cardiac surgery, many authors advocate bilateral upper limb blood pressure measurement and/or subclavian auscultation [2–10]. A difference in pressure of at least 20 mmHg between the two arms has a high positive predictive value for the presence of a significant SCA stenosis [2–8, 11], but is not always present owing to a well-formed collateral circulation [4] or the presence of diffuse atherosclerotic disease [3].

Given that many CABG patients will undergo carotid Duplex ultrasound as part of their pre-operative assessment, surprisingly few authors refer to evaluation of the VA Doppler waveform as a predictor of concomitant SCA disease, which is usually assessed during a carotid scan as a matter of routine. Marques et al [4] include the presence of partial or permanent flow reversal in the VA as one of three indications for pre-CABG prophylactic SCA stenosis treatment, acknowledging that even a mild proximal SCA stenosis can alter the VA waveform, although they do not describe the changes in VA waveform in detail. Completely retrograde or bi-directional VA flow are well documented, highly sensitive indicators of occlusion or significant (>50% diameter) stenosis of the ipsilateral SCA, respectively [12–16], although the correlation between the degree of change in VA waveform and the severity of ipsilateral SCA disease is only moderate. The presence of a mid-systolic notch during antegrade VA flow, as in the "bunny" waveform [14], appears sensitive to moderate (>45% diameter) SCA stenosis [13–15]. Infrequently, provocative tests are required to identify stress-induced VSSS, although the findings at rest will show antegrade vertebral flow that is significantly attenuated compared with the contralateral VA [17, 18]. The negative predictive value of a normal antegrade VA Doppler waveform is not well documented, presumably due to the unavailability of angiographic confirmation of the absence of SCA disease. Hence even slight alteration in the VA waveform should result in the direct identification of SCA disease, or at least strong suspicion of its presence which warrants further investigation if the lesion is not visible on Duplex.

In the presence of significant coronary artery disease, it would seem surprising that a significant SCA lesion would cause a coronary rather than a vertebral subclavian steal. At least one previous case report [19] acknowledges that CSSS occurred in a patient whose LIMA was anastomosed to a coronary artery whose degree of stenosis had initially been overestimated by suboptimal angiography. Their patient also had retrograde ipsilateral VA flow. Indeed, many reports imply [3, 6, 20–23] or explicitly note [2, 5, 24–26] retrograde VA filling in the presence of a coronary steal. Hence it would appear likely that concomitant vertebral and coronary subclavian steal is common, although there are two case reports [11, 27] demonstrating CSSS without reversal of vertebral flow in the presence of significant coronary artery stenosis. However, it would appear that our case is unique in the literature by virtue of the presence of antegrade vertebral flow interrupted in mid systole by a sharp deceleration (a "bunny" waveform).

There exist a range of treatment options for CSSS. Direct transthoracic revascularization (aorta to SCA bypass) and extrathoracic carotid-subclavian bypass [2, 3, 10] are popular procedures. There are few reports of the use of directional subclavian arthrectomy [11], or SCA recanalization using laser guide wire angioplasty [25]. In more recent years percutaneous transluminal angioplasty (PTA) and stenting have been the treatments of choice of CSSS [4–6]. To our knowledge no previous cases of CSSS secondary to in-stent restenosis have been reported, and in this case re-dilatation and re-stenting of the left SCA were performed.

Although few authors advocate diagnostic Duplex ultrasound as the primary imaging modality, in this case we were able to confirm the diagnosis of CSSS non-invasively allowing the patient to proceed directly to endovascular repair. We report what appears to be a previously unreported CSSS VA Doppler waveform and its resolution after successful percutaneous revascularization.

Received for publication January 20, 2003. Revision received June 16, 2003. Accepted for publication August 20, 2003.


   References
Top
 Abstract
 Case report
 Discussion
 References
 

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