Cardiovasc Interv and Ther DOI 10.1007/s12928-014-0284-2
CASE REPORT
Myocardial ischemia in a patient with peripheral vascular disease, an arteriovenous fistula, and patent coronary artery bypass grafts Ankush Moza • George V. Moukarbel • Christopher J. Cooper • Pradeep K. Bhat
Received: 30 March 2014 / Accepted: 25 June 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract Patients with coronary artery disease often have concurrent peripheral vascular disease. The presence of concurrent vascular pathologies can pose unique challenges among patients who have undergone coronary artery bypass grafting utilizing the left internal mammary artery. We describe a patient with peripheral vascular disease and prior history of coronary artery bypass grafting, who presented with recurrent anginal symptoms and an abnormal stress test despite the absence of significant residual unrevascularized coronary artery disease. Additional evaluation led to the identification of an ipsilateral severe subclavian stenosis with a concomitant ipsilateral upper extremity arteriovenous fistula. Patient’s symptoms resolved with the treatment of the underlying vascular lesions.
hemodynamic consequences that may lead to decreased blood flow to the distal myocardial bed from an ipsilateral internal mammary artery (IMA) graft (coronary steal syndrome). We report an instructive case of a patient with a left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass graft, who presented with anginal symptoms and an abnormal stress test despite patent bypass grafts who was eventually found to have concomitant subclavian stenosis and an arterio-venous (AV) fistula as the cause of his symptoms. He was treated with subclavian angioplasty and ligation of the fistula with subsequent resolution of his symptoms.
Case presentation Keywords AV fistula
Coronary subclavian steal LIMA
Introduction The presence of proximal subclavian stenosis or an upper extremity arteriovenous (AV) fistula can result in
A. Moza G. V. Moukarbel C. J. Cooper P. K. Bhat (&) Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, MS #1118, Toledo, OH 43614-2598, USA e-mail: [email protected] A. Moza e-mail: [email protected] G. V. Moukarbel e-mail: [email protected] C. J. Cooper e-mail: [email protected]
A 79-year-old man with a history of coronary artery disease (CAD) was admitted to the cardiac intensive care unit with anginal chest pains. He had an extensive history of arterial disease including peripheral, carotid, renal and subclavian artery disease for which he had undergone multiple surgical and percutaneous interventions. Notably, he had remote history of coronary artery bypass grafting (CABG) that included a LIMA to LAD bypass, a history of carotid endarterectomy, abdominal aortic aneurysmectomy, aorto-bifemoral bypass grafting, percutaneous interventions to femoral arteries and renal artery stents. During one of the previous catheterizations using the left brachial artery access with a 6 French sheath, the patient had guide wire related trauma with angiography suggesting the formation of a brachial AV fistula. In addition, 6 years prior to his current presentation, he had two Genesis stents placed in left subclavian artery proximal to the origin of the LIMA. Four months prior to his current presentation, he had coronary angiography for evaluation of chest pain that
123
A. Moza et al. Fig. 1 Single-photon emission computed tomography (SPECT) myocardial perfusion imaging demonstrating antero-apical reversible perfusion defect indicative of myocardial ischemia in the left anterior descending artery territory
demonstrated all previous bypass grafts to be patent. He was found to have a 95 % occlusive lesion in the distal left main continuing into the left circumflex artery and a 90 % in-stent restenosis of the left subclavian artery. The subclavian in-stent stenosis was treated with an iCAST stent and three overlapping drug-eluting stents were placed in the distal left main artery continuing into the proximal left circumflex artery after rotational atherectomy. Following the procedure, he became symptom-free and was doing well on medical management that included dual antiplatelet therapy, beta-blocker, calcium- channel-blocker, oral nitrate and statin. He was an ex-smoker with 25 packyears of smoking. Two weeks prior to the current presentation, he experienced recurrence of anginal chest pain occurring with decreasing levels of exertion progressing to symptoms present even at rest. On further evaluation, serial electrocardiograms (ECG) demonstrated dynamic T wave inversions in anterolateral leads during episodes of chest pain; however, cardiac enzymes were normal. A Regadenoson myocardial perfusion study was performed that demonstrated moderate sized antero-apical ischemia (Fig. 1). Further, an arterial Doppler of the left upper extremity was suggestive of proximal subclavian artery stenosis and a brachial AV fistula (Fig. 2). Therefore, it was thought that the antero-apical ischemia (myocardial territory supplied by the LIMA) may have been secondary to the proximal subclavian re-stenosis, and the ‘stealing’ of blood away from LIMA into the low resistance circuit of the distal subclavian artery due to the presence of the AV fistula. Subsequently, the patient underwent angiography that confirmed a moderately severe restenosis in the proximal subclavian artery (Fig. 3a). Given the calcific nature of the vessel and prior in-stent restenosis, an iCAST (covered) stent was chosen for its superior long-term patency in peripheral vascular disease [1] (Fig. 3b). Additionally, as
123
the brachial arterio-venous fistula was serving no useful purpose, a simultaneous surgical ligation of the brachial artery to brachial vein fistula was also performed. The patient was treated with dual antiplatelet therapy using aspirin and clopidogrel and systemic heparinization using intravenous unfractionated heparin was utilized during the interventions. On outpatient follow-up 3 months post-procedure, he reported resolution of his exertional angina and was doing well.
Discussion The IMA, a branch of the proximal subclavian artery, is widely utilized for CABG as it is associated with high patency rate and increased mid and long-term survival [2]. In addition, in the presence of extensive aortic atherosclerosis, the use of IMA, by minimizing the manipulation of the ascending aorta, reduces the risk of peri-operative systemic atheroembolism [2]. However, the subsequent development of ipsilateral subclavian artery stenosis may result in myocardial ischemia in the territory supplied by the corresponding IMA graft. This phenomenon has been described as coronary-subclavian steal syndrome (CSSS) [3]. The incidence of a critical stenosis or occlusion of the subclavian artery has been reported in 0.2–0.7 % of patients after CABG [4, 5]. The site of the subclavian stenosis to cause CSSS is usually proximal to LIMA origin and incidence of CSSS in patients with coronary artery disease ranges between 0.1 and 3.4 % [6]. Although our patient had an iatrogenic AV fistula, more commonly, patients with coronary and peripheral vascular disease have associated chronic kidney disease. In this setting, the construction of an upper extremity arteriovenous (AV) hemodialysis fistula ipsilateral to the IMA graft can result in additional hemodynamic challenges.
Coronary subclavian steal
Fig. 2 Arterial Doppler study of the proximal left subclavian artery with elevated velocities suggestive of high grade stenosis. Arterial Duplex of mid brachial artery demonstrates turbulent mono-phasic
waveform with elevated systolic and diastolic velocities consistent with the presence of an arterio-venous fistula
Symptomatic subclavian steal syndrome has been described in the setting of a high-output dialysis AV fistula without stenosis in the subclavian artery [7]. In these patients, reversal of LIMA flow is the result of extreme reduction in peripheral vascular resistance [2], and the consequent diversion of majority of the blood in the subclavian artery into its distal segment, away from the IMA [8]. A study utilizing phasic blood flow measurements showed that retrograde flow in the IMA during diastole could be reverted to normal antegrade flow by temporary occlusion of the ipsilateral AV fistula by a pneumatic cuff [8]. The substantial increase in the flow rate during hemodialysis sessions can further exacerbate this hemodynamic phenomenon [7–10]. It has been demonstrated that reduction in the flow in the IMA graft during hemodialysis is associated with concomitant regional wall motion abnormalities and anginal symptoms [2]. The combined hemodynamic effects of a significant ipsilateral proximal
subclavian artery stenosis and an ipsilateral distal AV fistula can result in significant ischemia despite an otherwise patent IMA graft [11]. While we did not measure the shunt volume at the brachial artery level quantitatively, the definitive test to evaluate the impact of the shunt in causing ischemia would be performing dynamic studies comparing flows in the arterial bed with and without compression over the shunt. Such dynamic studies are well described for peripheral circulation but may not be feasible for coronary circulation and, therefore, treatment is often guided by clinical judgment. Percutaneous and/or surgical correction of the underlying structural abnormality is the mainstay of treatment of patients with coronary ischemia related to subclavian steal. This is achieved through treatment of subclavian stenosis, and when feasible, ligation of an AV fistula. The latter procedure, especially if the AV fistula is small, may not always be necessary and does not need to be done
123
A. Moza et al. Fig. 3 a Angiography reveals moderately severe stenosis in the proximal left subclavian artery. b Angiography after revascularization with iCAST stent demonstrates restoration of normal flow in the subclavian artery
concurrent with the treatment of subclavian stenosis. However, in our patient, ligation of the AV fistula was performed as the iatrogenic fistula was serving no useful purpose. In patients requiring vascular access for hemodialysis, an alternate AV fistula may be constructed in the contra-lateral limb. Notably, unlike the conventional treatment of angina, the use of vasodilator medications may be unhelpful in the presence of a proximal flow-limiting structural lesion. In addition, such an approach may cause avoidable delay in offering definitive corrective treatment for the underlying structural vascular abnormality.
Conclusion
2.
3.
4.
5.
6. 7.
In patients with CABG and IMA grafts, an understanding of the hemodynamic consequences of an ipsilateral subclavian stenosis and an AV fistula is crucial. This would not only help physicians in planning optimal corrective procedures but also avoid potential diagnostic and therapeutic pitfalls while treating this otherwise high-risk patient population.
8. 9.
10.
11.
References 1. Marin ML, Veith FJ, Cynamon J, et al. Effect of polytetrafluoroethylene covering of Palmaz stents on the development of
123
intimal hyperplasia in human iliac arteries. J Vasc Interv Radiol. 1996;7(5):651–6. Gaudino M, Serricchio M, Luciani N, Giungi S, Salica A, Pola R, Pola P, Luciani G, Possati G. Risk of using internal thoracic artery grafts in patients in chroinc hemodialysis via upper extremity arteriovenous fistula. Circulation. 2003;107:2653–5. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol. 1999;33:1238–45. Fields WS, Lemak NA. Joint study of extracranial arterial occlusion: 7, subclavian steal: a review of 168 cases. JAMA. 1972;222:1139–43. Marques KM, Ernst SM, Mast EG, Bal ET, Suttorp MJ, Plokker HW. Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary-subclavian steal syndrome. Am J Cardiol. 1996;78:687–90. Carrascal Y, Arroyo J, Fuertes JJ, Echevarrı´a JR. Massive coronary subclavian steal syndrome. Ann Thorac Surg. 2010;90(3):1004–6. Schenk WG III. Subclavian steal syndrome from high-output brachiocephalic arteriovenous fistula: a previously undescribed complication of dialysis access. J Vasc Surg. 2001;33:883–5. KatoH IkawaS, HayashiA YokoyamaK. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg. 2003;75:270–1. Kotval PS, Shah PM, Berman H. Doppler diagnosis of subclavian steal due to arteriovenous hemodialysis fistula in the ipsilateral arm. J Ultrasound Med. 1989;8:697–700. Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis. 2002;40:852–5. Lee PY, Ng W, Chen WH. Concomitant coronary and subclavian steal caused by ipsilateral subclavian artery stenosis and arteriovenous fistula in a hemodialysis patient. Catheter Cardiovasc Interv. 2004;62(2):244–8.
CASE REPORT
Myocardial ischemia in a patient with peripheral vascular disease, an arteriovenous fistula, and patent coronary artery bypass grafts Ankush Moza • George V. Moukarbel • Christopher J. Cooper • Pradeep K. Bhat
Received: 30 March 2014 / Accepted: 25 June 2014 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2014
Abstract Patients with coronary artery disease often have concurrent peripheral vascular disease. The presence of concurrent vascular pathologies can pose unique challenges among patients who have undergone coronary artery bypass grafting utilizing the left internal mammary artery. We describe a patient with peripheral vascular disease and prior history of coronary artery bypass grafting, who presented with recurrent anginal symptoms and an abnormal stress test despite the absence of significant residual unrevascularized coronary artery disease. Additional evaluation led to the identification of an ipsilateral severe subclavian stenosis with a concomitant ipsilateral upper extremity arteriovenous fistula. Patient’s symptoms resolved with the treatment of the underlying vascular lesions.
hemodynamic consequences that may lead to decreased blood flow to the distal myocardial bed from an ipsilateral internal mammary artery (IMA) graft (coronary steal syndrome). We report an instructive case of a patient with a left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass graft, who presented with anginal symptoms and an abnormal stress test despite patent bypass grafts who was eventually found to have concomitant subclavian stenosis and an arterio-venous (AV) fistula as the cause of his symptoms. He was treated with subclavian angioplasty and ligation of the fistula with subsequent resolution of his symptoms.
Case presentation Keywords AV fistula
Coronary subclavian steal LIMA
Introduction The presence of proximal subclavian stenosis or an upper extremity arteriovenous (AV) fistula can result in
A. Moza G. V. Moukarbel C. J. Cooper P. K. Bhat (&) Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, MS #1118, Toledo, OH 43614-2598, USA e-mail: [email protected] A. Moza e-mail: [email protected] G. V. Moukarbel e-mail: [email protected] C. J. Cooper e-mail: [email protected]
A 79-year-old man with a history of coronary artery disease (CAD) was admitted to the cardiac intensive care unit with anginal chest pains. He had an extensive history of arterial disease including peripheral, carotid, renal and subclavian artery disease for which he had undergone multiple surgical and percutaneous interventions. Notably, he had remote history of coronary artery bypass grafting (CABG) that included a LIMA to LAD bypass, a history of carotid endarterectomy, abdominal aortic aneurysmectomy, aorto-bifemoral bypass grafting, percutaneous interventions to femoral arteries and renal artery stents. During one of the previous catheterizations using the left brachial artery access with a 6 French sheath, the patient had guide wire related trauma with angiography suggesting the formation of a brachial AV fistula. In addition, 6 years prior to his current presentation, he had two Genesis stents placed in left subclavian artery proximal to the origin of the LIMA. Four months prior to his current presentation, he had coronary angiography for evaluation of chest pain that
123
A. Moza et al. Fig. 1 Single-photon emission computed tomography (SPECT) myocardial perfusion imaging demonstrating antero-apical reversible perfusion defect indicative of myocardial ischemia in the left anterior descending artery territory
demonstrated all previous bypass grafts to be patent. He was found to have a 95 % occlusive lesion in the distal left main continuing into the left circumflex artery and a 90 % in-stent restenosis of the left subclavian artery. The subclavian in-stent stenosis was treated with an iCAST stent and three overlapping drug-eluting stents were placed in the distal left main artery continuing into the proximal left circumflex artery after rotational atherectomy. Following the procedure, he became symptom-free and was doing well on medical management that included dual antiplatelet therapy, beta-blocker, calcium- channel-blocker, oral nitrate and statin. He was an ex-smoker with 25 packyears of smoking. Two weeks prior to the current presentation, he experienced recurrence of anginal chest pain occurring with decreasing levels of exertion progressing to symptoms present even at rest. On further evaluation, serial electrocardiograms (ECG) demonstrated dynamic T wave inversions in anterolateral leads during episodes of chest pain; however, cardiac enzymes were normal. A Regadenoson myocardial perfusion study was performed that demonstrated moderate sized antero-apical ischemia (Fig. 1). Further, an arterial Doppler of the left upper extremity was suggestive of proximal subclavian artery stenosis and a brachial AV fistula (Fig. 2). Therefore, it was thought that the antero-apical ischemia (myocardial territory supplied by the LIMA) may have been secondary to the proximal subclavian re-stenosis, and the ‘stealing’ of blood away from LIMA into the low resistance circuit of the distal subclavian artery due to the presence of the AV fistula. Subsequently, the patient underwent angiography that confirmed a moderately severe restenosis in the proximal subclavian artery (Fig. 3a). Given the calcific nature of the vessel and prior in-stent restenosis, an iCAST (covered) stent was chosen for its superior long-term patency in peripheral vascular disease [1] (Fig. 3b). Additionally, as
123
the brachial arterio-venous fistula was serving no useful purpose, a simultaneous surgical ligation of the brachial artery to brachial vein fistula was also performed. The patient was treated with dual antiplatelet therapy using aspirin and clopidogrel and systemic heparinization using intravenous unfractionated heparin was utilized during the interventions. On outpatient follow-up 3 months post-procedure, he reported resolution of his exertional angina and was doing well.
Discussion The IMA, a branch of the proximal subclavian artery, is widely utilized for CABG as it is associated with high patency rate and increased mid and long-term survival [2]. In addition, in the presence of extensive aortic atherosclerosis, the use of IMA, by minimizing the manipulation of the ascending aorta, reduces the risk of peri-operative systemic atheroembolism [2]. However, the subsequent development of ipsilateral subclavian artery stenosis may result in myocardial ischemia in the territory supplied by the corresponding IMA graft. This phenomenon has been described as coronary-subclavian steal syndrome (CSSS) [3]. The incidence of a critical stenosis or occlusion of the subclavian artery has been reported in 0.2–0.7 % of patients after CABG [4, 5]. The site of the subclavian stenosis to cause CSSS is usually proximal to LIMA origin and incidence of CSSS in patients with coronary artery disease ranges between 0.1 and 3.4 % [6]. Although our patient had an iatrogenic AV fistula, more commonly, patients with coronary and peripheral vascular disease have associated chronic kidney disease. In this setting, the construction of an upper extremity arteriovenous (AV) hemodialysis fistula ipsilateral to the IMA graft can result in additional hemodynamic challenges.
Coronary subclavian steal
Fig. 2 Arterial Doppler study of the proximal left subclavian artery with elevated velocities suggestive of high grade stenosis. Arterial Duplex of mid brachial artery demonstrates turbulent mono-phasic
waveform with elevated systolic and diastolic velocities consistent with the presence of an arterio-venous fistula
Symptomatic subclavian steal syndrome has been described in the setting of a high-output dialysis AV fistula without stenosis in the subclavian artery [7]. In these patients, reversal of LIMA flow is the result of extreme reduction in peripheral vascular resistance [2], and the consequent diversion of majority of the blood in the subclavian artery into its distal segment, away from the IMA [8]. A study utilizing phasic blood flow measurements showed that retrograde flow in the IMA during diastole could be reverted to normal antegrade flow by temporary occlusion of the ipsilateral AV fistula by a pneumatic cuff [8]. The substantial increase in the flow rate during hemodialysis sessions can further exacerbate this hemodynamic phenomenon [7–10]. It has been demonstrated that reduction in the flow in the IMA graft during hemodialysis is associated with concomitant regional wall motion abnormalities and anginal symptoms [2]. The combined hemodynamic effects of a significant ipsilateral proximal
subclavian artery stenosis and an ipsilateral distal AV fistula can result in significant ischemia despite an otherwise patent IMA graft [11]. While we did not measure the shunt volume at the brachial artery level quantitatively, the definitive test to evaluate the impact of the shunt in causing ischemia would be performing dynamic studies comparing flows in the arterial bed with and without compression over the shunt. Such dynamic studies are well described for peripheral circulation but may not be feasible for coronary circulation and, therefore, treatment is often guided by clinical judgment. Percutaneous and/or surgical correction of the underlying structural abnormality is the mainstay of treatment of patients with coronary ischemia related to subclavian steal. This is achieved through treatment of subclavian stenosis, and when feasible, ligation of an AV fistula. The latter procedure, especially if the AV fistula is small, may not always be necessary and does not need to be done
123
A. Moza et al. Fig. 3 a Angiography reveals moderately severe stenosis in the proximal left subclavian artery. b Angiography after revascularization with iCAST stent demonstrates restoration of normal flow in the subclavian artery
concurrent with the treatment of subclavian stenosis. However, in our patient, ligation of the AV fistula was performed as the iatrogenic fistula was serving no useful purpose. In patients requiring vascular access for hemodialysis, an alternate AV fistula may be constructed in the contra-lateral limb. Notably, unlike the conventional treatment of angina, the use of vasodilator medications may be unhelpful in the presence of a proximal flow-limiting structural lesion. In addition, such an approach may cause avoidable delay in offering definitive corrective treatment for the underlying structural vascular abnormality.
Conclusion
2.
3.
4.
5.
6. 7.
In patients with CABG and IMA grafts, an understanding of the hemodynamic consequences of an ipsilateral subclavian stenosis and an AV fistula is crucial. This would not only help physicians in planning optimal corrective procedures but also avoid potential diagnostic and therapeutic pitfalls while treating this otherwise high-risk patient population.
8. 9.
10.
11.
References 1. Marin ML, Veith FJ, Cynamon J, et al. Effect of polytetrafluoroethylene covering of Palmaz stents on the development of
123
intimal hyperplasia in human iliac arteries. J Vasc Interv Radiol. 1996;7(5):651–6. Gaudino M, Serricchio M, Luciani N, Giungi S, Salica A, Pola R, Pola P, Luciani G, Possati G. Risk of using internal thoracic artery grafts in patients in chroinc hemodialysis via upper extremity arteriovenous fistula. Circulation. 2003;107:2653–5. Hadjipetrou P, Cox S, Piemonte T, Eisenhauer A. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol. 1999;33:1238–45. Fields WS, Lemak NA. Joint study of extracranial arterial occlusion: 7, subclavian steal: a review of 168 cases. JAMA. 1972;222:1139–43. Marques KM, Ernst SM, Mast EG, Bal ET, Suttorp MJ, Plokker HW. Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary-subclavian steal syndrome. Am J Cardiol. 1996;78:687–90. Carrascal Y, Arroyo J, Fuertes JJ, Echevarrı´a JR. Massive coronary subclavian steal syndrome. Ann Thorac Surg. 2010;90(3):1004–6. Schenk WG III. Subclavian steal syndrome from high-output brachiocephalic arteriovenous fistula: a previously undescribed complication of dialysis access. J Vasc Surg. 2001;33:883–5. KatoH IkawaS, HayashiA YokoyamaK. Internal mammary artery steal in a dialysis patient. Ann Thorac Surg. 2003;75:270–1. Kotval PS, Shah PM, Berman H. Doppler diagnosis of subclavian steal due to arteriovenous hemodialysis fistula in the ipsilateral arm. J Ultrasound Med. 1989;8:697–700. Crowley SD, Butterly DW, Peter RH, Schwab SJ. Coronary steal from a left internal mammary artery coronary bypass graft by a left upper extremity arteriovenous hemodialysis fistula. Am J Kidney Dis. 2002;40:852–5. Lee PY, Ng W, Chen WH. Concomitant coronary and subclavian steal caused by ipsilateral subclavian artery stenosis and arteriovenous fistula in a hemodialysis patient. Catheter Cardiovasc Interv. 2004;62(2):244–8.
