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J Thorac Cardiovasc Surg 1998;115:464-465
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Treatment of internal thoracic artery steal syndrome withsupraclavicular approach

Thessaloniki, Greece

From the Department of Cardiac Surgery, St. Luke's Hospital,Thessaloniki, Greece.

Received for publication June 16, 1997 Accepted for publication June 30, 1997. Address for reprints: A. D. Bisbos, MD, A. Nastou 12 Str.,Thessaloniki 542 48, Greece.

The routine use of internal thoracic artery (ITA) has simplified itsharvesting technique, but there are still circumstances in which it is difficultto ligate the major branches. It would be great help if the ITA were included inpreoperative cardiac catheterizations.

Postoperative steal syndrome may occur because of a large patent branchof the ITA, alone or in conjunction with high coronary vascular resistance. Thediagnosis is a combination of the clinical picture, a positive stress testresult, and the selective ITA angiogram. ¹The condition is dealt with either in the catheterization lab with embolizationof the ITA branch or in the operating room with surgical ligation of the branch(with a medial resternotomy, a lateral thoracotomy, a lateral parasternalintercostal incision, or a left supraclavicular incision). The occlusion of thebranch with microcoil embolization is easy and essentially quick, but itrequires the correct equipment. The procedure is at times only partiallysuccessful, and there are cases in which recanalization has occurred. ^2,3

The medial resternotomy is tedious because of adhesions; there is adanger of injuring the ITA, and, if the branch is located extremely proximally,it is difficult to ligate. ¹ Aleft lateral thoracotomy is relatively easy but has the disadvantage of one morelarge incision, possible postoperative complications, and delayed recovery. Aleft parasternal intercostal incision has the advantage of a small incision, butthe operative field is limited and there are adhesions. Finally, there is thepossibility of surgical ligation with the left supraclavicular incision. Withthis approach, we have been able to ligate the branch safely, quickly (meanoperative time 15 to 20 minutes), and with no adhesions and minimalrepercussions for the patient. This is the best method for branches that arelocated extremely proximally.

We have dealt with three cases of ITA steal syndrome. These threepatients had early postoperative angina (2 to 8 months after the operation) anda positive thallium 201 stress test result. Two patients had hypertrophicmyocardium, and the third had a history of an old anterior myocardialinfarction. Cardiac angiography revealed patent vein grafts. The left ITA wasalso patent, with a large side branch that originated 1 to 4 cm distal to thebeginning of the left ITA. There was a decrease in the diameter of the ITAperipherally from the beginning of the branch (Fig. 1).

View larger version (118K): [in this window] [in a new window]   Fig. 1. Cardiac angiogram inpatient with history of anterior myocardial infarction reveals patent veingrafts and left ITA. Note a large side branch, which was producing stealsyndrome.

Spasm of the ITA was not observed. The postoperative courses of thesethree patients were uneventful, and they were discharged the day after theoperation. They were screened by catheterization to ascertain that the ligationof the branch was intact. Their angina had disappeared, and their stress testresults were negative. The patients were free of symptoms at 2 years after theoperation.

Discussion. The flow of the ITA isinfluenced by blood pressure and resistance of the coronary vascular network.Some surgeons do not dissect the ITA proximally and medially to the thymusgland, but this may leave a large pericardial or thymic branch unligated. Someauthors have noted that if the subclavian artery does not have significantstenosis and the coronary vascular network is intact, then the unligatedbranches will not cause ischemia and will not influence the patency of ITA. ⁴ Others have reported a significantdecrease in the diameter of the ITA peripherally to the origin of the largebranch. ⁵ Seki and colleagues ⁶ noted that patients with ITA stringsign had no postoperative angina pectoris clinically or during a controlledcheck with thallium 201. They observed a decrease in the diameter of the ITAperipheral to the branch, but the width of the lumen (about 2 mm) was sufficientfor the perfusion of the left anterior descending coronary artery. Theyspeculated that the postoperative diameter of the ITA is associated with thedegree of stenosis and flow of the coronary vessel.

We believe that if coronary vascular resistance is high (bad vascularbed, hypertrophic myocardium) or the coronary vessel has no critical stenosis (>70%)and there is a highly patent branch (>30% of the diameter of the ITA),it is possible for the steal phenomenon and angina pectoris to occur. The leftsupraclavicular incision offers immediate, complete, and relatively safetreatment for the patient with postoperative angina pectoris caused by a stealfrom a high unligated ITA branch. It has little negative effect on the generalwell-being of the patient. The actual surgical time required is minimal (20minutes), and the results are immediate. The patients can be discharged from thehospital the next day.

References

1. Pelias A, Del Rossi A. A case ofpostoperative internal mammary steal. J Thorac Cardiovasc Surg 1985;90:794-6.
   
2. Mishekel G, Willinsky R. Combined PTCA andmicrocoil embolization of a left internal mammary artery graft. CathetCardiovasc Diagn 1992;27:141-6.
   
3. Sbarouni E, Corr L, Fenech A. Microcoilembolization of large intercostal branches of internal mammary artery grafts.Cathet Cardiovasc Diagn 1994;31:334-6.[Medline]
   
4. Ivert T, Huttunen K, Landou C, Bjork V.Angiographic studies of internal mammary artery grafts 11 years after coronaryartery bypass grafting. J Thorac Cardiovasc Surg 1988;96:1-12.[Abstract]
   
5. Singh R, Sosa J. Internal mammary arterycoronary artery anastomosis: influence of the side branches on surgical result.J  Thorac Caardiovasc Surg 1981;82:909-14.[Abstract]
   
6. Seki T, Kitamura S, Kawachi K, et al. Aquantitative study of postoperative luminal narrowing of the internal thoracicartery graft in coronary artery bypass grafting. J Thorac Cardiovasc Surg 1992;104:1532-8.[Abstract]
   

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