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Subclavian artery stenosis in a patient undergoing coronary bypass using composite t-grafting technique: is it subclavian artery stenosis or more?/Kompozit T-greft teknigi kullanilan koroner baypasli bir hastada subklavian arter stenozu: subklavian arter stenozu ya da fazlasi?

Introduction

Occlusive arterial disease of the upper extremity occurs at a much lower frequency than disease of the lower extremity. They are mostly seen in the subclavian and the innominate artery. The common cause is atherosclerosis (1). With an increase in the use of internal mammarian artery in heart surgery, detection of subclavian artery stenosis (SAS) has gained importance. In a patient with history of coronary bypass surgery (CABG) 6 months ago, we determined SAS. What makes this case interesting is that left internal mammarian artery (LIMA) was anastomosed to the left anterior descending artery (LAD); furthermore, the proximal anastomoses of the arterial grafts belonging to the circumflex (CX) and the right coronary arteries (RCA) were anastomosed to LIMA using the composite T-grafting technique. Hence, perfusion of the heart was rendered totally dependent on LIMA and consequently on the left subclavian artery.

Case Report

A 65-year-old woman was admitted to our clinic with pulmonary edema. Her medical history revealed that she had undergone coronary artery bypass grafting with a LIMA conduit to the LAD and with a composite T-grafting technique applied to the RCA and CX six months ago. On examination, the blood pressure was 60/40 mmHg in the right arm and there was no pulse in the left arm. The electrocardiogram showed normal sinus rhythm. Transthoracic echocardiography revealed severe left ventricular dysfunction. Oxygen inhalation, dopamine infusion and IV furosemide was administered. Pulmonary edema regressed and the patient's condition stabilized. Coronary angiography revealed cut-off in all the major coronary arteries. In addition, in the selective aortic arc vessel angiography, the left subclavian artery had a stenosis of 90% at 2 cm distal to its origin (Fig. 1). The LIMA-LAD graft was patent. The radial artery graft to the CX and RCA was anastomosed to LIMA from its proximal (Fig. 2, 3). Cardiac perfusion was totally dependent on LIMA and consequently on the left subclavian artery. Angioplasty was not appropriate because of the severe lesion angle (approximately 90[degrees]). The patient was referred to vascular surgery. She underwent left carotid-left subclavian bypass with a Dacron graft. She was discharged on the postoperative 5th day and has remained symptom-free for 1 year since surgery.

Discussion

SAS is a very rare disorder of the arterial tree and has gained clinical importance with an increase in the use of LIMA as a graft in coronary bypass surgery. It is generally caused by atherosclerotic disease. Other etiological factors include arteritis, neurofibromatosis, fibromuscular dysplasia, radiation, posttraumatic scarring and compression syndromes (2-5). The incidence is reported to be up to 3.4% after CABG (6). SAS can be the cause of various phenomena, namely the subclavian steal syndrome, coronary-subclavian steal syndrome (CSS) and ischemic symptoms without steal due to diminished blood flow (1).

Although the patients are usually asymptomatic, the symptoms are usually due to either distal ischemia due to stenosis or embolic events, particularly ischemia occurring during upper extremity exercise because of diminished blood flow to the left arm, to the cerebrovascular circulation. Symptoms include angina, lightheadedness, left arm numbness or weakness, silent ischemia, heart failure, and myocardial infarction (7). CSS should be suspected when there are symptoms of vertebrobasilar insufficiency, arm claudication, and differential upper arm systolic blood pressure greater than or equal to 20 mmHg (8). Definitive diagnosis requires angiographic evaluation of the aortic arch. Hemodynamically significant stenosis can be ruled out by simple bilateral brachial artery BP measurement rather than routine angiography. In addition, computed tomography, magnetic resonance angiography and duplex ultrasonography are also available for the diagnosis (9).

The treatment options for SAS are surgery or percutaneous transluminal angioplasty and stenting. Percutaneous intervention has recently gained popularity because it is less invasive. A review by Ribichini et al. (10) summarized the success and safety of percutaneous treatment of these lesions.

In our case, there was no steal, but there was severe myocardial ischemia due to diminished blood flow to LIMA in which there was distal subclavian stenosis. A careful evaluation before the operation for preventing of this syndrome is essential.

Conclusion

Although SAS is very rare and the patients are usually asymptomatic, it has clinical importance in patients with CABG, especially those with composite T-grafting technique. Patients with angina undergoing CABG using LIMA grafting should be considered in terms of left SAS as a possible cause of myocardial ischemia.

doi: 10.5152/akd.2013.151

References

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(2.) Andros G, Schneider PA, Harris RW, Dulawa LB, Oblath RW, Salles-Cunha SX. Management of arterial occlusive disease following radiation therapy. Cardiovasc Surg 1996; 4: 135-42. [CrossRef]

(3.) Smith TP, Halbach VV, Fraser KW, Teitelbaum GP, Dowd CF, Higashida RT. Percutaneous transluminal angioplasty of subclavian stenosis from neurofibromatosis. AJNR Am J Neuroradiol 1995; 16(4 Suppl): 872-4.

(4.) Tyagi S, Verma PK, Gambhir DS, Kaul UA, Saha R, Arora R. Early and long-term results of subclavian angioplasty in aortoarteritis (Takayasu disease): comparison with atherosclerosis. Cardiovasc Intervent Radiol 1998; 21: 219-24. [CrossRef]

(5.) Cingoz IF Bingol H, Ozal E, Tatar H. Coronary subclavian steal syndrome in a patient with Behcet's disease. Thorac Cardiovasc Surg 2010; 58: 244-6. [CrossRef]

(6.) Lobato EB, Kern KB, Bauder-Heit J, Hughes L, Sulek CA. Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery. J Cardiothorac Vasc Anesth 2001; 15: 689-92. [CrossRef]

(7.) Sadek MM, Ravindran A, Marcuzzi DW, Chisholm RJ. Complete occlusion of the proximal subclavian artery post-CABG: presentation and treatment. Can J Cardiol 2008; 24: 591-2. [CrossRef]

(8.) Marshall WG Jr, Miller EC, Kouchoukos NT. The coronary-subclavian steal syndrome: report of a case and recommendations for prevention and management. Ann Thorac Surg 1988; 46: 93-6. [CrossRef]

(9.) Zebele C, Ozdemir HI, Hamad MA. Coronary ischemia due to subclavian stenosis after arterial revascularization. Asian Cardiovasc Thorac Ann 2011; 19: 169-71. [CrossRef]

(10.) Ribichini F Maffe S, Ferrero V, Cotroneo A, Vassanelli C. Percutaneous angioplasty of the subclavian artery in patients with mammary-coronary bypass grafts. J Interv Cardiol 2005; 18: 39-44. [CrossRef]

Address for Correspondence/Yazisma Adresi: Dr. Arif Arisoy, Ataturk Universitesi Tip Fakultesi, Kardiyoloji Anabilim Dali, Erzurum-Turkiye

Phone: +90 442 316 63 33

E-mail: arfarsy@hotmail.com

Available Online Date/Cevrimici Yayin Tarihi: 27.05.2013

Arif Arisoy, Selim Topcu, Huseyin Karal, Serdar Sevimli

From Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum-Turkey
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Article Details
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Arisoy, Arif; Topcu, Selim; Karal, Huseyin; Sevimli, Serdar
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Case study
Date:Aug 1, 2013
Words:1063
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