AN UNLIKELY SUSPECT: CORONARY-SUBCLAVIAN STEAL SYNDROME
Journal of the American College of Cardiology
Background: Coronary arterial insufficiency due to subclavian steal is most common in those who have undergone coronary artery bypass surgery using the left internal mammary artery (LIMA). Flow reversal can cause symptoms of chest pain or shortness of breath, similar to that of myocardial infarction. Case: A 66 year old female with coronary artery bypass grafts presented with dyspnea and chest discomfort. Chest CT ruled out pulmonary embolism, but revealed calcifications of the aorta (Figure 1A-B). Stress test exhibited reversible ischemia of the anteroapical wall. Subsequent cardiac catheterization showed patency of the LIMA graft with retrograde flow to the left subclavian artery from the left anterior descending insertion site (Figure 1C). Attempt to engage the LIMA via the subclavian artery was unsuccessful as it was met with 100% proximal occlusion (Figure 1D-E). Decision-making: In the case of symptomatic coronary-subclavian steal, endovascular intervention is appropriate for proximal stenosis that is short and will not jeopardize integrity of the vertebral artery or LIMA. Studies show that stenting after angioplasty was superior to angioplasty alone, therefore, a 6 mm x 22 mm covered stent was placed across the lesion with excellent antegrade flow (Figure 1F). Conclusion: Coronary-subclavian steal can be difficult to diagnose when symptoms could be mistaken for myocardial infarction. However, in a patient with history of LIMA graft, proximal subclavian artery stenosis should be suspected
9 Supplement 1
Bernardo, Marie; Beasley, Michael; Marciano, Paolo; and Dabbous, Samir, "AN UNLIKELY SUSPECT: CORONARY-SUBCLAVIAN STEAL SYNDROME" (2019). Articles. 317.