Coronary steal

Coronary steal

The term ‘coronary steal’ (CS) is basically diversion of coronary flow from one artery to another. It can be either between from one coronary territory to another or from coronary territory to a non coronary territory. Different such scenarios can be found in literature.

Abnormal stress test due to large anomalous vessels supplying a large left atrial myxoma producing CS has been reported [1]. Symptoms and abnormal stress test response resolved after resection of the tumour and ligation of the abnormal vessels.

Another situation is CS into a coronary cameral fistula connecting a coronary artery branch to the left ventricle [2]. Rupture of a coronary artery aneurysm into the right atrium in a patient with systemic lupus erythematosus and sepsis resulted in inferior wall myocardial infarction due to CS [3]. Angina and positive stress test occurred in a patient with a fistula connecting left anterior descending coronary artery to left superior pulmonary vein [4].

CS and ischemia can occur due to a patent side branch in left internal mammary artery (LIMA) to coronary artery bypass graft (CABG) [5]. Coil embolization of the LIMA side branch produced relief of CS and ischemia.

Multiple coronary micro fistulae into the ventricles due to persistent Thebesian veins is another rare cause of coronary steal [6]. These cases are not amenable to any surgical measures, but respond to usual antianginal medications other than coronary vasodilators. Coronary vasodilators can theoretically worsen the coronary steal phenomenon.

CS can occur in post CABG patients with a LIMA graft if the subclavian gets occluded. A post CABG patient who had LIMA to left anterior descending coronary artery (LAD) with bilateral subclavian-carotid artery graft occlusion presented with non ST elevation myocardial infarction [7]. The patient was successfully treated with endovascular procedures in the cardiac catheterization laboratory.

References

1. Stiver K, Bittenbender P, Whitson BA, Bush CA. Left atrial myxoma causing coronary steal: an atypical cause of angina. Tex Heart Inst J. 2015 Jun 1;42(3):270-2.
2. Carvalho NV, Desouza DA, Desouza KA, Beohar N. Coronary steal phenomenon from a coronary artery to left ventricular fistula. Eur Heart J Cardiovasc Imaging. 2015 Feb;16(2):176.
3. Hirata K, Yagi N, Wake M, Takahashi T, Nakazato J, Miyagi T, Shimotakahara J. Coronary steal due to ruptured right coronary aneurysm causing myocardial infarction in a patient with systemic lupus erythematosus. Cardiovasc Diagn Ther. 2014 Aug;4(4):333-6.
4. Barsoum EA, Saiful FB, Asti D, Morcus R, Khoueiry G, Lafferty J, McCord DA. Rare case of coronary to pulmonary vein fistula with coronary steal phenomenon. World J Cardiol. 2014 Jul 26;6(7):682-4.
5. Moreno N, da Silva Castro A, Pereira A, Silva JC, Almeida PB, Andrade A, Maciel MJ, Pinto P. Ischemia induced by coronary steal through a patent mammary artery side branch: a role for embolization. Rev Port Cardiol. 2013 Jun;32(6):531-4.
6. Khoueiry G, Baydoun H, Abi Rafeh N, McCord D, Olkovky Y. Persistent thebesian vessels involving the right and left ventricles leading to coronary steal phenomena and ischemia. Congenit Heart Dis. 2014 Mar-Apr;9(2):E61-5.