The
coronary-subclavian steal syndrome involves the siphoning of blood from the myocardium through an internal mammary artery graft because of a proximal
subclavian artery stenosis or occlusion, and results in
myocardial ischemia. With the increased use of the internal mammary artery for
myocardial revascularization, the potential exists for recurrence of
angina pectoris in patients who have or in whom develops high-grade
stenosis or occlusion of the subclavian artery, because of the
coronary-subclavian steal syndrome. The
coronary-subclavian steal syndrome can be prevented by the identification of patients with or at risk to develop subclavian artery occlusive disease. All patients undergoing cardiac catheterization prior to
coronary artery bypass grafting in which use of the internal mammary artery is anticipated should be evaluated for the presence of upper extremity and cerebrovascular
ischemia, the presence of cervical or supraclavicular bruits, and an upper extremity blood pressure differential of 20 mm Hg or greater. Patients with these findings or with evidence of diffuse atherosclerotic
vascular disease should have brachiocephalic arteriography at the time of coronary arteriography to identify significant subclavian artery occlusive disease. When this is demonstrated, use of the internal mammary artery as a free graft instead of an in situ graft or use of saphenous vein grafts is indicated. Patients in whom recurrent angina develops following
coronary artery bypass grafting that included an internal mammary artery graft should have coronary arteriography to evaluate the presence of
coronary-subclavian steal syndrome, and brachiocephalic arteriography. Carotid-subclavian bypass grafting, probably best done with a prosthetic conduit, is the procedure of choice for management of the
coronary-subclavian steal syndrome.