A 50-year-old female with a history of coronary artery disease (CAD) status post three-vessel coronary artery bypass grafts (CABG), ischemic cardiomyopathy (ejection fraction [EF] = 15%), left subclavian occlusion status post carotid to subclavian artery bypass, and type 2 diabetes mellitus presents for advanced heart failure therapy evaluation. In the past few months, she was admitted several times to her local hospital for heart failure exacerbations. Her inpatient evaluation identified reversible anterior ischemia on a nuclear perfusion study, but her coronary angiogram at the outside hospital did not reveal any new coronary stenosis. It was notable for patent bypass grafts, patent carotid to subclavian bypass, and no progression of the native coronary artery disease. After aggressive diuresis and ongoing optimal medical therapy, she was still limited from a functional standpoint. Her physicians elect to repeat her diagnostic cardiac catheterization. Initial angiography is performed via right femoral access. Angiogram of her native left coronary system revealed retrograde flow up the left internal mammary artery (LIMA) graft and to the left subclavian artery (Videos 1 and 2). Her native subclavian artery stenosis, proximal to the LIMA graft, is still present (Video 3). These findings explain the hypoperfusion of the anterior myocardium found on the nuclear study. Her final diagnosis is coronary steal syndrome.
Angiography in the left carotid demonstrating flow to the subclavian artery. In the late phase, demonstration of retrograde LIMA flow.
Angiography in the left coronary system demonstrating retrograde flow up the LIMA to subclavian artery.
Given this scenario, which of the following statements describes the best treatment approach for this patient's coronary steal syndrome?
The correct answer is: C. Percutaneous intervention to the subclavian artery to improve flow from the aortic arch.
Several points highlight answer C as the best option. First, the patient had clearly failed medical therapy as demonstrated by her repeat hospitalizations. Second, her nuclear perfusion study demonstrated reversible ischemia and, therefore, viable myocardium. Coiling of the LIMA graft would likely result in worsening myocardial ischemia. Surgical revision or a completely new revascularization procedure to improve flow to the subclavian artery may work, but these choices would mean repeated high-risk surgery in the setting of known ischemic myocardium. Additionally, these surgeries could potentially compromise other vascular structures. Video 1 is an injection at the base of the left carotid artery. This demonstrates flow to the left subclavian artery; in the late phase, there is retrograde flow from the LIMA. Video 2 further demonstrates this retrograde flow in greater detail. Finally, Video 3 shows that there is 100% stenosis of the left subclavian artery. Therefore, her physicians elect to implant a stent across her subclavian stenosis. Her physicians successfully perform percutaneous intervention on the subclavian artery via the left radial artery. They use a 5 French Terumo radial sheath and 5 French MPA1 LBT Guide. An 0.035 x 260 cm Emerald J wire is used to cross the lesion, followed by successful pre-dilation with two inflations of a 4.0 x 60 mm Mustang balloon to 8 atm. Finally a 7 mm x 27 mm Express Biliary LD bare-metal stent is deployed at 12 atm across the lesion (Video 4). She has no complications during the intervention, and her symptoms remarkably improve. At her three-month follow-up, she has no repeat heart failure hospitalization and is clinically doing well.
Successful placement of 7 x 27 mm stent via left radial access.
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