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A man aged 77 years with a medical history of first coronary artery bypass grafting (CABG) 18 years before and a redo bypass grafting three years before the present admission suffered from prolonged resting angina. Redo CABG had been performed for unstable angina and underlying three vessel disease with occlusion of two venous grafts and a critical stenosis of the venous graft to the left descending artery (LAD). The left internal mammal artery (LIMA) had been anastomosed onto the LAD while the right coronary artery and the left circumflex artery were bypassed using saphenous grafts.
Clinical examination was characterised by a significant difference in blood pressure between both arms (right 130/80 mm Hg and left 90/60 mm Hg). The ECG showed a sinus rhythm with a complete left bundle branch block. Serial cardiac enzyme and troponin measurements were normal. Diagnostic coronary angiography revealed patent bypass grafts but a critical stenosis of the left subclavian artery just proximal to the origin of the LIMA was present (panel A, arrow).
A percutaneous coronary intervention session was planned using a direct stenting technique over a 0.035 inch wire without using a guiding catheter via a femoral access. The final result was angiographically perfect and the patient was free of angina or other complications afterwards (panel B, arrowhead).
Severe stenosis or total occlusion of the left subclavian artery may lead to myocardial ischaemia due to reduced or reversed blood flow through a LIMA bypass graft to the coronary artery. The frequency of this rare phenomenon called coronary subclavian steal syndrome is reported to be between 0.4–1.1% in CABG patients.
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