Coronary-Subclavian Steal Syndrome: Case Series and Review of Therapeutic Aspects

Background: Coronary-subclavian steal syndrome (CSSS) is a clinical condition characterized by the reversal of blood flow in the left internal thoracic artery (ITA) in patients who have undergone coronary revascularization using this artery. It is a rare cause of myocardial ischemia subsequent to stenosis or occlusion of the subclavian artery (SA) proximal to ITA coronary bypass. Proximal subclavian artery (SA) stenosis is present and atherosclerotic disease is the underlying pathophysiologic mechanism in the majority of cases. We report a series of patients with late CSSS treated through an endovascular approach. Methods: The clinical data of 4 consecutive patients with CSSS who had undergone subclavian artery stenting between 2015 and 2019 were reviewed. The anatomic and clinical-angiographic characteristics of the series were considered. Follow-up was performed and a review of the therapeutic aspects is provided. Results: From January 2015 to December 2019, 4 patients with CSSS were treated; 3 had stable and 1 unstable angina. Of the 4 patients, 3 had left SA stenosis (2 ostial to the origin and 1 in the middle segment), 1 had proximal occlusion of the left SA. Arterial access was at the brachial artery through surgical exposure. In 1 case of proximal occlusion of the left SA, simultaneous femoral and percutaneous brachial access was necessary. Predilatation of the stenotic lesion was performed in all cases. Balloon expandable stents were used in all patients with proximal ostial stenosis or occlusion and self-expandable stents in 1 with nonostial lesion. No patients developed angina during the follow-up period (12+4 months). Conclusions: Endovascular therapy with angioplasty and subclavian artery stenting is a treatment of choice for CSSS, due to the high success rates, minimally invasive procedure, and low morbidity and mortality rates. This condition should always be suspected in patients with a history of myocardial revascularization, clinical angina, and asymmetry between upper limb pulses.