Coronary-subclavian steal phenomenon late after coronary artery bypass grafting: an underappreciated cause of myocardial ischemia?

Coronary-subclavian steal (CSS) is an increasingly reported phenomenon after coronary artery bypass graft (CABG) operation and it is caused by proximal subclavian artery stenosis in patients with internal thoracic artery grafts. We discuss briefly the diagnostic strategies to rule out significant subclavian stenosis before CABG and, in the follow-up, the importance of subclinical detection of coronary-subclavian steal before the potential onset of myocardial ischemia. Although the most appropriate management of concomitant brachiocephalic and coronary artery disease remains a matter of debate, patients developing CSS syndrome after CABG can be treated successfully by both surgical and percutaneous techniques. Retrospective analysis of surgical databases will help to identify the predictors, if any, of subclavian artery disease progression in candidates for internal thoracic artery grafting, in order to choose a tailored surgical approach.