• Images in cardiology

A 53 year old woman with multiple risk factors for ischaemic heart disease (hypercholesterolaemia, ex-smoker, family history, severe peripheral vascular disease) presented with an acute coronary syndrome in April 2001. Coronary angiography showed mild left main stem disease and a severe left anterior descending (LAD) stenosis. Urgent off-pump bypass grafting was performed, placing the left internal mammary artery (LIMA) to the LAD. Two months later she was admitted with recurrence of angina and found to have occlusion of the graft at the insertion site. This was successfully stented and the patient’s symptoms resolved. At review the following year she reported increasing limitation caused by angina (Canadian Cardiovascular Society grade 3). Myocardial perfusion imaging revealed reversible ischaemia in the anterior wall, raising the possibility of in-stent restenosis.

Femoral and left radial access was attempted unsuccessfully and therefore repeat coronary angiography was performed via the right radial artery. An aortic injection revealed a left subclavian artery stenosis and demonstrated feasibility of access from the left femoral artery.

The left subclavian artery was tackled by direct stenting using a 13.0 mm × 5.0 mm Tetra stent (Guidant) (panels A and B). Angiography showed the LIMA to be patent, without significant in-stent restenosis. The patient remained free of angina at six months follow up.

In patients with recurrence of angina following LIMA grafting, left subclavian artery stenosis should be considered as a possible cause for myocardial ischaemia, especially in patients with peripheral vascular disease.