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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 85-86

Coronary steal phenomenon in post CABG patients


Department of Cardiology, Caremax Superspeciality Hospital, Jalandhar, Punjab, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Rajen Maniar
C/o Caremax Superspeciality Hospital, 333, Lajpat Nagar, Near Guru Nanak Mission Chowk, Jalandhar - 144 001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_14_19

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  Abstract 


Encountering a coronary subclavian steal syndrome phenomenon is a rare opportunity. We came across three such cases. Article describes unique cases of two elderly males and one female who underwent CABG few years ago and presented with recurrent chest pain symptoms.

Keywords: Coronary artery bypass graft, coronary steal, left internal mammary artery


How to cite this article:
Chawla R, Ahmad W, Maniar R, Sharm V. Coronary steal phenomenon in post CABG patients. Heart India 2019;7:85-6

How to cite this URL:
Chawla R, Ahmad W, Maniar R, Sharm V. Coronary steal phenomenon in post CABG patients. Heart India [serial online] 2019 [cited 2019 Jul 20];7:85-6. Available from: http://www.heartindia.net/text.asp?2019/7/2/85/261830




  Background Top


Most frequently used graft for coronary artery bypass graft surgery (CABG) is the left internal mammary artery (LIMA) but its side branches to the chest wall are common. The internal mammary arteries are always first choice for left anterior descending (LAD) revascularization because of superior patency rates and improved survival. A LIMA bypass graft side branches can cause myocardial ischemia post-CABG by “stealing” blood flow and directing it to the internal mammary artery.[1] According to Singh and Sosa, post-CABG angina might develop because of the diversion of blood flow from the myocardium into the intercostal branches of the internal mammary artery. These side branches needed to be ligated at the time of surgery.[2] It is a matter of debate that un-ligated side branches of LIMA can steal the blood flow away from LAD making patients symptomatic.


  Case Reports Top


Case 1

We describe a case of a 65 year old female with a history of CABG surgery 1 year back, presented with recurrent episodes of chest pain from the past 6 months. Check angiography done 6 months' post-CABG revealed normally functioning vessels and graft for instance LAD ostial 100% occlusion, LIMA to LAD patent, other coronaries normal.

Recurrent chest pain persistent, despite aggressive medical management, required recurrent admissions with ST-T changes in anterior leads, troponin T-negative, echo study showed normal left ventricular (LV) function, thallium study showed ischemia in apico-anterior wall. Check angiography again revealed normally functioning vessels and LIMA graft.

New observation was made of huge muscular branch arising from proximal LIMA supplying scapular/shoulder muscles. Could this branch be a cause of ischemia due to steal phenomenon? Working on this differential diagnosis as a cause of angina, the intervention was planned for occluding muscular branch through the left radial approach.

Guiding Catheter 7F JR4 and Guide wire 0.014 balance middle weights (BMW) were used for very tortuous LIMA branch. Wire was kept into muscular branch and 7F guide was cut distally by 30 cm followed by guiding Catheter 5F JR 4 introduced into 7F Guide over BMW wire. Successful embolization of LIMA branch done after deep manipulation of guide into LIMA branch using device vascular plug 6mm.

Follow-up after 5 years, the patient remained asymptomatic, repeat thallium study showed no residual ischemia.

Case 2

We describe a case of a 70-year-old male with a history of CABG surgery 3 years back, presented with recurrent episodes of chest pain from the past 1 year and increased intensity and frequency of pain from the past 2 weeks along with mild ST T changes in anterior leads. Troponin T was negative, echo showed normal LV function, thallium study was positive for ischemia in anterior wall. Check angiography done revealed left main normal, LCx ostial 100% occlusion, saphenous vein graft (SVG) to Om graft normal, right coronary artery (RCA) normal, LAD ostial 100% occlusion, LIMA to LAD patent with residual muscular branch to shoulder and relatively sluggish flow of LAD (? thrombolysis in myocardial infarction [TIMI] II flow).

Could it be steal phenomenon? Working on this hypothesis, the intervention was planned for occluding muscular branch through the femoral approach.

Catheter 6F LIMA and Guide Wire 0.014 BMW were used. Micro-ferret catheter 0.018 negotiated distally. Embolization coil (5 mm × 5mm) delivered Successful. Closure of LIMA branch with very clear improvement of LAD flow observed. Significant improvement of LAD flow was seen immediately.

The patient remained asymptomatic in further follow-ups. Thallium study was negative after 2 weeks.

Case 3

We describe a case of a 58-year-old male with a history of CABG surgery 5 years back, presented with recurrent episodes of chest pain for the past 6 months and mild ST T changes in lateral leads. Troponin T was negative, echo showed normal LV function, thallium study was positive for ischemia in lateral wall. Check angiography done revealed left main normal, ×LC normal, LAD prox. LIMA to LAD showed About 99% occlusion with residual multiple large sternal branches and relatively sluggish flow of LAD (TIMI II flow), RCA was occluded in mid segment and SVG to PDA was normal. SVG to PDA was normal.

Could it be steal phenomenon? Working on this hypothesis Intervention was planned for Occluding muscular branch through the femoral approach.

Catheter 6F LIMA and Guide Wire 0.014 BMW were used. Micro-ferret catheter 0.018 negotiated distally. Embolization coil (5 mm × 5 mm) delivered successfully. Closure of LIMA branch with very clear improvement of LAD flow observed.

The patient remained asymptomatic in further follow-ups. Thallium study was negative after 2 weeks.

Decision-making

These cases exemplify that in cases of post-CABG ischemia, one should have low threshold of check angiography and importance of considering late consequences of CABG in patients with multi-vessel disease who present with shortness of breath (SOB) and angina. In patients with CABG, it is important to check for patency of the side branches of the LIMA graft after surgery. Occluding the side branches will diminish the chances of developing coronary steal phenomenon preventing further unnecessary invasive procedures such as coil embolization. Nonconventional causes should be looked for. Documented nonconventional cause as actual etiology rather than ocular reflex. Modification of routine interventional techniques may be required (vascular plug/coil embolization) need strict follow-up.


  Conclusion Top


It is important to consider differential diagnoses other than coronary artery occlusion as a cause of angina and SOB in patients who have had CABG.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Biceroglu S, Karaca M, Yildiz A, Ildizli Demirbas M, Yilmaz H. Can left internal mammary artery side branches affect blood flow rate? Cardiovasc J Afr 2009;20:119-21.  Back to cited text no. 1
    
2.
Singh RN, Sosa JA. Internal mammary artery – Coronary artery anastomosis. Influence of the side branches on surgical result. J Thorac WCardiovasc Surg 1981;82:909-14.WW  Back to cited text no. 2
    




 

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