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Asian Cardiovasc Thorac Ann 1998;6:328
© 1998 Asia Publishing EXchange Pte Ltd

LETTER TO THE EDITOR

Proximal Obstruction of Left Subclavian Artery After Coronary Artery Bypass Surgery

Hakan Ceyran, MD, M Halit Andaç, MD, Alper Kunt, MD, Ramazan Asik, MD

Department of Cardiothoracic Surgery Erciyes University Medical School Kayseri 38039, Turkey
A patient who had coronary artery bypass grafting in 1986 and angioplasty in 1993 was admitted to our hospital recently with chest pain and dyspnea of 5 months duration. Blood pressure in the right upper extremity was 120/70 mm Hg, while it was 70/40 mm Hg in the left. Angiography indicated total occlusion of the right coronary and circumflex arteries. The left internal thoracic artery (ITA) was patent but the left subclavian artery showed delayed filling and subclavian steal (Figure 1Go). The left subclavian artery was explored via an incision through the left supraclavicular space. The left subclavian artery and the left external carotid artery were snared proximally and distally and a 6-mm polytetrafluoroethylene graft was anastomosed end-to-side between the carotid artery and the subclavian artery, close to the origin of the left internal thoracic artery. In the post-operative period, the left arm arterial blood pressure reached 110/65 mm Hg. Angiography showed that the graft was patent with good filling of the left internal thoracic artery (Figure 2Go). The patient was discharged in good condition on the 3rd postoperative day with anti-coagulant therapy. He was symptom-free at the 6-month follow-up.



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  		Figure 1. Preoperative angiography.

 


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  		Figure 2. Postoperative angiography.

 
The phenomenon of subclavian steal is defined as narrowing or complete obstruction proximal to the origin of the vertebral artery in the subclavian artery. Blood coming from the carotid system and the vertebral artery on the opposite side, flows into the Willis polygon, and then downwards to the vertebral artery retrogradely to pass into the subclavian artery distal to the obstruction.1 Arterial occlusive disease affecting the proximal innominate or subclavian arteries may be asymptomatic or it may produce disabling symptoms of upper extremity ischemia or vertebrobasilar insufficiency.2

The ITA is widely used for myocardial revascularization and its long-term patency is well-established. Arteriosclerosis may directly affect the ITA and proximal sub-clavian stenosis may compromise ITA flow. The standard treatment for this was carotid-subclavian transposition.3 An alternative is insertion of a graft between the carotid and subclavian arteries. In addition, there is extraanatomic inter-subclavian bypass.4 We created a bypass between the carotid artery and the subclavian artery in our patient with favorable early results. The long-term patency of this type of graft is reported to be 95%.4

REFERENCES

  1. Edwards WH Jr, Tapper SS, Edwards WH Sr, Mulherin JL, Martin RS, Jenkins JM. Subclavian revascularization. Ann Surg 1994;219:673–8.[Medline]

  2. Vitti MJ, Thompson BW, Read RC, Gagne PJ, Borone GW, Barnes RW. Carotid-subclavian bypass: a twenty- two-year experience. J Vasc Surg 1994;20:411–8.[Medline]

  3. Holmes JR, Crane R. Coronary steal through a patent internal mammary artery graft: treatment by subclavian angioplasty. Am Heart J 1993;125:1166–7.[Medline]

  4. Synn AY, Chalmers RA, Sharp WJ, Hoballah JJ, Kresowik TF, Corson JD. Is there a conduit of preference for a bypass between the carotid and subclavian arteries? Am J Surg 1993;166:157–62.[Medline]





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