Endovascular Treatment of a Complex Chronic Total Occlusion of Left Subclavian Artery in a Patient with Coronary-Subclavian Steal Syndrome

Abstract

A 72-year-old female patient presented with progressive dyspnea; chest pain with minimal exertion that resolved with rest; and debilitating dizziness that worsened with activity. Our case demonstrates successful complex endovascular treatment of a long chronic total occlusion of the proximal left subclavian artery where a LIMA graft supplied the only remaining patent coronary vessel.

VASCULAR DISEASE MANAGEMENT 2012;9(3):E39–E41

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Case Report

A 72-year-old female presented with progressive dyspnea and chest pain with minimal exertion that resolved with rest. She also complained of debilitating dizziness that worsened with activity, for which she remained sedentary in order to avoid symptoms. Past medical history was significant for coronary artery disease status post coronary artery bypass grafting (CABG) 12 years prior involving a left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD) and 2 saphenous vein grafts. In addition to a history of previous stroke, type 2 diabetes, hypertension, and dyslipidemia, she also had extensive peripheral vascular disease and had undergone a right carotid endarterectomy and a left femoral-popliteal bypass graft 24 years prior to admission.

Coronary angiography, following admission, was remarkable for a 60% eccentric stenosis in the left main coronary artery, moderate diffuse disease in the LAD, and occluded left circumflex and right coronary arteries that filled via collaterals from the LAD. Saphenous vein grafts were occluded along with the left subclavian artery, which had a long chronic occlusion at the ostium with retrograde filling of the distal subclavian artery and LIMA graft via the left vertebral artery.

Access was obtained in the left brachial artery and a 25 cm 6 Fr sheath advanced into the subclavian artery for initial angiography, which confirmed a long occlusion of the proximal left subclavian artery (Figure 1) and reversal of flow in the LIMA as well as the left vertebral artery.  We attempted to cross the occlusion with a Crosser high-frequency ablation catheter (FlowCardia Inc.), albeit unsuccessfully. Next, a 0.018-inch Astato 30 gm wire (Asahi Intecc) was introduced for a prolonged attempt at recanalization. However, the distal exit point of the subclavian into the aorta was difficult to delineate. For this reason, access was obtained in the right femoral artery and a 6 Fr internal mammary catheter advanced to the ostium of the left subclavian in an attempt at crossing the occlusion from an antegrade approach using another Astato 30 gm wire without success. Ultimately after prolonged manipulation of both Astato wires from retrograde and antegrade approaches, the wire from the brachial access was successful in crossing the occlusion into the ascending aorta (Figure 2). After aggressive balloon angioplasty, a 5 x 19 mm Express stent (Boston Scientific) was deployed in the ostial segment of the subclavian artery followed by a 5 x 15 mm Express stent in an overlapping fashion with care not to jail the LIMA graft, and these stents post-dilated using a 6 x 20 mm Sterling balloon (Boston Scientific). Final angiography performed through the internal mammary catheter revealed significantly improved angiographic result with restoration of antegrade flow through the LIMA (Figure 3).

The patient tolerated the procedure well and was discharged to an inpatient rehabilitation facility 7 days after her intervention. She was seen in follow-up 1 month later and reported complete resolution of her chest pain and markedly diminished dyspnea.

Discussion

Subclavian steal syndrome (SSS), an infrequent manifestation of subclavian artery stenosis or occlusion proximal to the origin of the vertebral artery, was first described by Miller-Fischer in 1961.¹ Reduction or absence of flow in the proximal subclavian artery reverses the normal direction of blood flow in the vertebral artery as blood is drawn from the contralateral vertebral, basilar, or carotid artery to provide flow in the affected subclavian artery distal to the stenosis.¹ Symptoms, although uncommon, arise from the reversal of blood flow in the vertebral artery, and is termed “steal” since it effectively robs blood from the cerebral circulation to supply the affected upper extremity,¹ resulting in vertebrobasilar insufficiency and may include headache, blurred vision, impaired consciousness, vertigo, dysarthria, or other neurologic symptoms during use of the affected upper extremity.²

A subset of SSS patients, who have undergone CABG using the LIMA as a conduit, may present with myocardial ischemia in a condition termed coronary-subclavian steal syndrome (CSSS).³ The LIMA graft is used as a preferred conduit to bypass the LAD during CABG due to excellent long-term patency and improved clinical outcomes when compared to saphenous vein grafting.⁴ CSSS is a condition in which severe stenosis or obstruction of the subclavian artery causes ischemia or even reversal of blood flow from the myocardium supplied by the LIMA graft.⁵  In CABG patients, the frequency of subclavian stenosis is low (0.44%-1.1%)^5,6 and the incidence of CSSS is rare (0.07%-0.44%).⁷ However, CSSS should be suspected in the setting of recurrent anginal symptoms in patients who have undergone CABG using a LIMA graft with no significant progression of native coronary or bypass graft disease.

Subclavian stenosis can be diagnosed with ultrasonography,⁸ computed tomography (CT) angiography,⁹ magnetic resonance imaging (MRI),² or with invasive angiography,10 and ideally should be diagnosed prior to bypass using a LIMA graft. Bilateral upper extremity blood pressure measurements are useful in screening for stenosis: a systolic blood pressure difference of 20 mm Hg is highly suggestive of subclavian artery stenosis and warrants further preoperative imaging or angiography.¹⁰

Although the optimal treatment for CSSS is not known, it has traditionally been treated with surgery. Due to high morbidity and mortality rates associated with transthoracic approaches, extrathoracic revascularization with common carotid to subclavian bypass grafting using a prosthetic graft (Dacron or polytetrafluoroethylene) or with carotid-subclavian transposition has emerged as the surgical treatment of choice.^10-12 Contemporary surgical treatment provides primary patency rates of 97%-100% at 1 year, 91%-98% at 3 years, and 83%-96% at 5 years.^11,13-15 Perioperative mortality falls in the range of 0%-1.7%,11-14 stroke rate of up to 3.3%,^11,13-15 and nonfatal morbidity of 6%-8%.^11,14

Endovascular treatment of SSS was first described by Bachman and Kim in 1980.¹⁶ Since then, endovascular treatment of subclavian stenosis has become commonplace.¹⁷ Several series demonstrate a 100% initial success rate for percutaneous treatment of subclavian stenosis,^18-22 although initial success for total occlusions of the subclavian artery has been reported as low as 46%-65%.^18,20,21 Endovascular treatment provides patency rates approaching those of surgery: Sullivan et al reported an 84% primary patency rate at an average of 35 months;¹⁹ Henry et al obtained a patency rate of 84.5% at an average of 2.9 years;²¹ and de Vries et al reported a primary patency rate of 89% at 5 years.²⁰ At a mean follow-up of 29 months, Westerband et al had a restenosis rate of 15.3%. However, these lesions were successfully treated percutaneously to achieve an assisted patency rate of 100%.²² Endovascular treatment of subclavian stenosis has a combined perioperative stroke and death rate of 0.9%-3.6% and a minor complication rate of 2.6%-4.5%,^20,21 results which compare favorably with surgical revascularization.^11,14 Additionally, patients treated with percutaneous revascularization may be spared the risk of complications unique to surgery including thoracic duct injury, recurrent laryngeal nerve injury, and vocal cord paralysis, phrenic nerve palsy, and bradyarrhythmia.^11-13 Furthermore, endovascular approaches for management of CSSS have been described with excellent outcomes and patency rates.^23,24

Herein, our case demonstrates successful complex endovascular treatment of a long chronic total occlusion of the proximal left subclavian artery, where the LIMA graft supplied the only remaining patent coronary vessel. Although we report a successful result at 1 month follow-up, further observation and follow-up is necessary to conclude long-term treatment success.

References

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From the Division of Cardiovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey.
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 submitted January 9, 2012, provisional acceptance given January 23, 2012, final version accepted February 7, 2012.
Address for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, USA. Email: georgej@deborah.org