Simultaneous Preoperative Brachiocephalic Angiography and Coronary Angiography to Prevent Coronary-Subclavian Steal Syndrome in Coronary Surgery Candidates
Background: Whether or not preoperative brachiocephalic angiography with left internal mammary artery (LIMA) visualization should be performed at the time of coronary angiography in patients in whom bypass grafting using LIMA is envisaged is still debated. We sought to assess the role of the routine brachiocephalic angiography artery in preventing the coronary-subclavian steal syndrome in patients who are candidates for bypass grafting using LIMA.
Methods: Medical records of 110 patients (mean age 69.3 ± 8.4 years) who underwent concomitant coronary angiography and brachiocephalic arteriography between May 1998 and December 2002 were reviewed. Stenosis >50%, vessel occlusion, and aneurysm were noted as significant findings.
Results: Significant findings were observed in 23/110 patients (20.9%). Five patients with subclavian artery stenosis and upper limb ischemia underwent subclavian artery angioplasty and stenting and bypass surgery using LIMA. During a mean follow-up of 24.7 ± 10.7 months, only one patient developed a new subclavian artery disease after bypass grafting using LIMA, and underwent subclavian artery angioplasty. Logistic regression analysis revealed 3-vessel CAD (odds ratio (OR) 9.917 ; 95% confidence interval (CI) 2.2 to 43.8; P = .002), hypercholesterolemy (OR 2.74; CI 95% 1.05 to 7.7; P = .044), and age >65 (OR 3.55; CI 95% 2.2 to 9.2, P = .038) to be predictors of brachiocephalic disease.
Conclusion: This study suggests that routine angiography of the brachiocephalic arteries at the time of coronary angiography is effective in preventing coronary-subclavian steal syndrome in select patients who are candidates for bypass grafting using LIMA.
Alcala JE, Alvarez M, Tercedor L et al. 1997. Usefulness of the angiographic examination of the left internal mammary artery in patients candidates for coronary bypass surgery. Rev Esp Cardiol 50: 113-6.nBicknell CD, Subramanian A, Wolfe JH. 2004. Coronary subclavian steal syndrome. Eur J Vasc Endovasc Surg 27:220-1.nCha KS, Kim MH. 2002. Feasibility and safety of concomitant left internal mammary arteriography at the setting of the right transradial coronary angiography. Catheter Cardiovasc Interv 56:188-95.nChen CW, Lin TK, Chen BC et al. 2004. Preoperative semi-selective left internal mammary artery angiography: easy, safe, necessary, and worthy. J Cardiovasc Surg (Torino) 45:107-10.nFeit A, Reddy CV, Cowley C et al. 1992. Internal mammary artery angiography should be a routine component of diagnostic coronary angiography. Cathet Cardiovasc Diagn 25:85-90.nMarshall WG Jr, Miller EC, Kouchoukos NT. 1988. The coronary-subclavian steal syndrome: report of a case and recommendations for prevention and management. Ann Thorac Surg 46:93-6.nRigatelli G, Franco GF, Rigatelli G. 2001. Complete angiographic view of the coronary-subclavian steal syndrome. Heart 85:22.nRigatelli G, Zanchetta M. 2004. Interventional treatment of noncoronary atherosclerosis: what the cardiologist would know. Ital Heart J 5:99-113.nVan Son JA, Aengevaeren WR, Skotnicki SH et al. 1989. Diagnosis and management of the coronary-subclavian steal syndrome. Eur J Cardiothorac Surg 3:565-7.n