[Coronary-subclavian steal syndrome].

OBJECTIVE

Presentation of 3 consecutive cases of coronary-subclavian steal syndrome, with special attention to clinical evolution, diagnosis, treatment strategies and outcomes.

MATERIAL AND METHODS

We present three consecutive cases of male patients, aged 60 to 69 years (average: 63 years) with hypertension, dyslipidemia, and smoking as the most prevalent cardiovascular risk factors. The 3 cases had a history of previous coronary revascularization using the left internal mammary artery to the anterior descending coronary, with an interval of 4 months to 4 years before the onset of symptoms, 2 of the cases with stable angina, 1 with V4 to V6 ST segment depression in the exercise test and 1 with myocardial infarction with no ST segment elevation. None of the patients had left upper limb claudication. In 2 patients, no left radio-cubital pulse was detected at rest being weak in the third. All patients had atherosclerotic obliteration of the left subclavian artery, 2 with occlusion and 1 with stenosis >90%. Cardiac catheterization was the diagnostic exame in all cases. The interval between diagnosis and intervention was 6 to 13 weeks (median of 9 weeks). We chose the endovascular treatment with balloon expandable stent. The preferred access route was the left humeral artery in 2 cases and the femoral artery in the third.

RESULTS

In all patients the revascularization was achieved, without residual stenosis. Angiography after revascularization, disclosed antegrade flow in all patients through the left internal mammary artery. Recovery of the symmetry of pulses was noticed in all the patients, no signs or symptoms of myocardial ischemia were presented in two of them, with nonspecific pre-cordial symptoms remained in the third, after effort. All patients were discharged with dual antiplatelet therapy for a period not less than 3 months.

CONCLUSION

The coronary-subclavian steal syndrome is a rare cause of myocardial ischemia after coronary revascularization (0.1% to 6%), as a result of proximal arterial occlusive disease, with subsequent hemodynamic, being atherosclerosis the main etiology. Although the surgical route has been the treatment of choice in the past, endovascular revascularization emerged nowadays as the first-line treatment, with recent studies demonstrating high patency at the 2nd and 5th year after angioplasty (100% and 85% to 95%) and low morbidity and mortality. Further doubts arise about the role of double antiplatelet therapy, having been chosen, in this series, treatment of at least 3 months.