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Coronary–subclavian steal syndrome is an uncommon cause of recurrent angina following internal mammary bypass.
A 63 year old patient with history of moderate hypertension, type 2 diabetes, and dyslipidaemia presented with recurrent angina one year after left internal mammary to left anterior descending coronary artery bypass and saphenous vein graft to right coronary artery bypass.
Physical examination showed a murmur in the subclavian region. Transthoracic echocardiography demonstrated normal left ventricle end diastolic volume and ejection fraction and a moderate ipokinesis of the anterior and apical regions of the left ventricle.
The patient underwent coronary and subclavian artery angiography for suspected coronary–subclavian steal syndrome. The coronary angiogram showed a subocclusion of the proximal portion of the left anterior descending coronary artery and reversal flow in the internal mammary artery graft, a severe stenosis of the left circumflex coronary artery, and an occlusion of the middle portion of the right coronary artery. The bypass angiogram revealed the patency of the vein graft. The internal mammary artery was not selectively catheterised because of the proximal occlusion of the left subclavian artery. The internal mammary artery graft was shown by selective angiography of the right vertebral artery and it revealed a collateral flow through the left vertebral artery, to the left subclavian and internal mammary arteries (top, middle and bottom, white arrows). The left vertebral artery had an ostial subcritical stenosis (middle, white arrow). The protection against cerebral ischaemia offered by the vertebral lesion might explain the absence of cerebral symptoms.
The patient underwent percutaneous angioplasty of the subclavian artery, left circumflex artery, and left anterior descending coronary artery, which led to a rapid improvement in the patient's symptoms.
Performance of coronary and brachiocephalic angiography is indicated in recurrent angina in patients with internal mammary artery bypass graft. When possible, revascularisation of the subclavian artery is the treatment of choice for the coronary–subclavian steal syndrome.