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Coronary subclavian steal from a left internal mammary artery coronary bypass graft due to ipsilateral subclavian artery stenosis
Date Issued |
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2022-06-02 |
Non-Surgical Case Report III
e-ISBN 978-83-965593-0-2
Background: Coronary subclavian steal syndrome (CSSS) is a rare incidence in patients with prior coronary artery bypass grafting (CABG) and, specifically, a left internal mammary artery (LIMA) to the left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. Case report: An 84-year-old woman with a history of coronary artery disease, status post triple vessel CABG with a LIMA-LAD, vein grafts to the right coronary artery, and a diagonal branch was admitted to department of Cardiology of our hospital. Her chief complain was intermittent chest pain radiating to the left arm exacerbating on moderate exercise; also, she noted different blood pressure (BP) between arms for a while. On physical examination, vitals were normal, except the difference of BP between arms; in the left arm it was 50 mmHg lower compared to right one. The 12-lead ECG revealed ST depression and negative T waves in left-sided leads. Cardiac biomarkers were normal. Echocardiography showed reduced left ventricle ejection fraction (LVEF). Coronary artery angiography (CA) revealed formerly occluded native coronary arteries. Both two vein grafts were patent. Retrograde blood flow from LIMA to the left subclavian artery and left subclavian artery stenosis were found. As the heart was fully revascularized, it was presumed that CSSS was the cause of her symptoms. Vascular surgeon recommended percutaneous transluminal angioplasty (PTA). Stenosis was ballooned and stented, which re-established blood flow. The patient was asymptomatic after the procedure and was discharged the following day. On 30-day follow up, her chest pain recovered and her physical capacity improved. Conclusion: CSSS should be highly suspected in patients with differential blood pressure readings and angina symptoms after CABG. Retrograde flow through the LIMA graft in patients with significant left subclavian stenosis can foremost be diagnosed by invasive angiography.