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A 67 year old man, who had undergone coronary artery bypass graft surgery two years previously, represented with crescendo angina. Repeat diagnostic coronary and graft angiography demonstrated severe native coronary disease with a patent radial artery graft to the posterior descending artery and a severely and diffusely diseased saphenous vein graft to the obtuse marginal. Cannulation of the left subclavian artery to facilitate visualisation of the left internal mammary artery graft proved technically difficult, because of an inability to advance the 0.038 inch J wire beyond an apparent occlusion of the vessel proximally (left panel).
Following administration of intra-arterial glyceryl trinitrate and alteration of the position of the patient’s arm from behind the head to by his side, the subclavian artery was well visualised (middle panel) and the internal mammary graft shown to be free of disease. Returning the arm to its original position behind the head again resulted in compression of the left subclavian artery immediately beneath the clavicle (right panel). Percutaneous intervention was then successfully undertaken to the culprit lesion in the proximal left circumflex.
Prolonged positioning of the left arm behind the head during graft angiography may result in compression of the left subclavian artery between the clavicle and the first rib anteriorly; repositioning of the arm by the side alleviates artefactual occlusion and facilitates visualisation of the left internal mammary artery.