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Don’t Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome
J INVASIVE CARDIOL 2021;33(2):E145. doi:10.25270/jic/20.00164
Key words: cardiac imaging, post-CABG complication, subclavian steal syndrome
Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Nuclear myocardial perfusion imaging showed reversible perfusion defect to 20% of the left ventricular myocardium. Subsequent coronary angiogram was unchanged from previous study, with the exception of a novel 90% left SCA ulcerated stenosis with gradient of 41 mm Hg (Figure 1A). The visualized SCA stenosis and angina with arm raise were concerning for mechanical obstruction and subsequent “steal” physiology, or retrograde flow from the LIMA to the poststenotic SCA. As a result, the patient underwent percutaneous coronary angiography to the left SCA with a 7 x 27 mm Visi-Pro stent (Medtronic), resulting in a normal-caliber vessel (Figure 1B). At follow-up, angina had resolved.
Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.
From 1the Department of Internal Medicine and 2Department of Cardiology, Augusta University Medical Center, Augusta, Georgia.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted April 1, 2020.
Address for correspondence: Michael Coles, MD, Department of Cardiology, Augusta University Medical Center, 1120 15th Street, Augusta, GA 30912. Email: michaeljohncoles@gmail.com
