Circulation: Cardiovascular Interventions. 2008;1:82-84
doi: 10.1161/CIRCINTERVENTIONS.108.769968
Images and Case Reports in Interventional Cardiology |
Unstable Angina as a Result of Coronary-Subclavian Steal Syndrome
Michal Lelek, MD
;
Tomasz Bochenek, MD
;
Janusz Drzewiecki, MD, PhD
and
Maria Trusz-Gluza, MD, PhD
From the I Department of Cardiology, Medical University of Silesia, Katowice, Poland.
Correspondence to Tomasz Bochenek, MD, I Department of Cardiology, Medical University of Silesia, Ziolowa Street 45-47, 40-635 Katowice, Poland. E-mail tbochun{at}poczta.onet.pl
A 75-year-old man was transferred to our department from the local hospital because of recurrent episodes of dyspnea and angina at rest, with significant 3.0-mV ST-segment depressions in ECG leads V3 through V6. His medical history was significant for coronary artery disease, 2-vessel coronary artery bypass grafts (1999), nondisabling stroke (2004), type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The patient also complained of dizziness and weakness of the left hand. Clinical examination was characterized by lack of radial pulse, and blood pressure could not be measured on the left arm. The echocardiogram showed apex and inferior wall hypokinesis with slightly diminished ejection fraction (50%).
Ultrasound examination revealed occlusion of the left internal carotid artery and reversed flow through the left vertebral artery, confirmed by angiography (Figure 1). Symptomatic vertebral-subclavian steal syndrome was diagnosed.
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Figure 1. Contrast injection into the brachiocephalic trunk and reversed flow through the left vertebral artery in late phase. The figure is a composite of 2 images obtained during different phases of the same injection: early- and late-phase contrast filling.
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Angiography of the left coronary artery showed the entire left
internal mammary artery (LIMA) graft (
Figure 2) with reversed
flow of contrast into the subclavian artery. The right and circumflex
coronary arteries were occluded, as well as the venous graft
to the right coronary artery. Contrast injection into the subclavian
artery demonstrated critical 90% stenosis in the proximal part
of the subclavian artery, with a translesion pressure gradient
of 80 mmHg (
Figure 3). Contrast selectively injected beyond
the lesion merely showed the proximal parts of the left vertebral
artery and LIMA, indicating the presence of reversed flow. Direct
stenting of the subclavian artery was performed (
Figure 4),
and anterograde flow through the left vertebral artery and LIMA
was reestablished. Control coronary angiography revealed only
minor retrograde filling of the distal part of the LIMA, indicating
that the subclavian angioplasty had produced favorable results
(
Figure 5). At discharge from the hospital, the patient was
asymptomatic and the left radial pulse was palpable. Although
subclavian steal syndrome is rather rare, it can be manifested
as acute coronary syndrome among patients with LIMA grafts or
vertebrobasilar insufficiency, especially in the presence of
concomitant internal carotid artery occlusion. Percutaneous
angioplasty is the preferred treatment option for those patients.
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Acknowledgments
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Disclosures
None.
