Percutaneous Angioplasty and Stenting of Left Subclavian Artery Stenosis in Patients with Left Internal Mammary-Coronary Bypass Grafts: Clinical Experience and Long-Term Follow-up

Abstract

The authors report their experience with percutaneous transluminal angioplasty (PTA) and stenting of the left subclavian artery (LSA) in patients with recurrent angina and a left internal mammary (LIMA)-coronary bypass graft or in patients who will be undergoing LIMA-coronary artery bypass grafting. From November 1990 to February 2001, 21 patients (1 1 men and 10 women) with significant left subclavian artery stenosis were treated; 18 patients had a prior LIMA bypass graft, and 3 patients were treated before coronary artery bypass surgery. Angiographic follow-up was performed in 12 patients and clinical follow-up was obtained in all patients. All lesions were atherosclerotic in etiology and located in the proximal left subclavian artery. The mean stenosis was 81% (range 50-100%). All patients initially underwent PTA. Stents were placed in 7 patients for suboptimal PTA results. Technical success was achieved in all patients. Pressure gradient measurements were available in 6 patients. Mean pretreatment gradient was 29 mm Hg (range, 10-50 mm Hg) and fell to 3 mm Hg (0-8 mm Hg) posttreatment. There were 2 minor and 2 major complications. The 30-day mortality rate was 9.5% (2 patients). The remaining 19 patients had clinical or angiographic follow-up of 4-68 months (mean, 27 months). Three patients were found to have recurrent stenoses by angiography 8-43 months after PTA and 3 more had clinical signs of recurrent stenosis. Therefore, the long-term clinical patency rate of LSA PTA and stent was 15 of 19 (79%). One was managed with bypass surgery, 1 with repeat PTA and stent placement, and 1 was managed conservatively. Therefore, the assisted patency was 15 of 19 (79%). Eleven of 19 (58%) of the patients in long-term follow-up had cardiac symptoms, but repeat angiography excluded recurrent LSA stenosis as the cause of their symptoms in 7 cases. Only 4/19 (2 1%) had cardiac symptoms potentially attributable to LSA restenosis. Four patients expired during follow-up, but 3 had no evidence of subclavian stenosis. PTA and stenting is an effective treatment of proximal left subclavian artery stenosis in patients who develop angina after a LIMA-coronary artery bypass, or in patients before a LIMA-CABG. Cardiac symptoms after LSA PTA and stent are most often due to progressive coronary artery disease rather than to recurrent LSA stenosis.