title: Endovascular therapy in prevention and management of coronary-subclavian steal.
abstract: BACKGROUND
  The optimal management of patients undergoing coronary artery bypass grafting (CABG) who have proximal subclavian artery stenosis (SAS) is not well established. SAS may lead to flow reversal through a patent in situ internal mammary artery graft, resulting in myocardial ischemia (coronary-subclavian steal). We review our experience in prevention and management of coronary-subclavian steal.
  
  
  METHODS
  The medical records of patients who received treatment of symptomatic coronary-subclavian steal were reviewed. Patients who underwent subclavian artery revascularization before CABG were also included in our review. Patient demographic data, findings at presentation, imaging and treatment methods, and short-term and intermediate-term results were analyzed.
  
  
  RESULTS
  Over 4 years, 14 patients with combined subclavian and coronary artery disease were identified. Nine patients had angina (n = 8) and/or congestive heart failure (n = 2) after CABG (post-CABG group). Four patients underwent treatment of SAS and one underwent treatment of recurrent stenosis before or during CABG (pre-CABG group). Among this pre-CABG group, one patient had symptoms of left arm claudication; the other four patients had no symptoms. A blood pressure gradient was commonly noted between both arms. An angiogram confirmed the proximal location of SAS in all patients, and established the presence of flow reversal in a patent internal mammary artery graft in the post-CABG group. Operative management consisted of percutaneous transluminal angioplasty (PTA) and stenting of the subclavian lesion in 11 patients, PTA only in 2 patients, and carotid-subclavian bypass grafting in 1 patient. No known perioperative complications or morbidity was encountered in either group. Mean follow-up was 29 months, during which stenosis recurred in two patients, along with associated cardiac symptoms. In both patients repeat angioplasty was successful, for an assisted primary patency rate of 100%.
  
  
  CONCLUSIONS
  PTA and stenting to treat SAS appears to provide effective protection from and treatment of coronary-subclavian steal over the short and intermediate terms. A surveillance program is essential because of the risk for recurrent stenosis. Continued follow-up is necessary to determine long-term efficacy of this treatment compared with more conventional surgical approaches.
authors.affiliation: Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, PO Box 245072, Tucson, AZ 85724, USA. halex94@aol.com
authors.forename: Alex
authors.initials: A
authors.lastname: Westerband
authors.forename: Julio A
authors.initials: JA
authors.lastname: Rodriguez
authors.forename: Venkatesh G
authors.initials: VG
authors.lastname: Ramaiah
authors.forename: Edward B
authors.initials: EB
authors.lastname: Diethrich
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000800:Angioplasty, Balloon; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003327:Coronary Disease / Q000150:complications / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D015607:Stents; D013348:Subclavian Artery / Q000000981:diagnostic imaging; D013349:Subclavian Steal Syndrome / Q000150:complications / Q000000981:diagnostic imaging / Q000517:prevention & control / Q000628:therapy*