Myocardial ischaemia due to stenosis of the subclavian artery

The internal thoracic artery is often used for reconstruction of coronary arteries. In a proportion of cases the reason for bypass failure (internal thoracic artery - coronary artery) is abnormal blood flow in the subclavian artery resulting from its stenosis. The stricture can result from post-surgery progression of atherosclerosis or could have been present and undiagnosed already when cardiac surgery was performed. This may result in exercise angina or even acute coronary syndrome. Interventional intervention is inevitable in these cases. An 84-year-old man was admitted for unstable angina 7 years after coronary artery bypass grafting (CABG) from the internal thoracic artery to the left anterior descending branch of the left coronary artery In spite of medical treatment the symptoms did not recede and coronary and bypass angiography was performed on the 4(th) day of hospitalization, revealing multiple stenoses of the coronary arteries and severe stenosis of the left subclavian artery Moreover, the symptoms subsided only slightly after angioplasty of the circumflex branch of the left coronary artery. For this reason, angioplasty of the left subclavian artery with stent implantation, widening of the right coronary artery aortic opening, and angioplasty of the left coronary artery trunk and of the circumflex branch at its origin were performed. These procedures resulted in complete cessation of angina, while the patient also observed significant improvement of his left upper limb performance. The coronary-subclavian steal syndrome is defined as reduced flow through the bypass (internal thoracic artery - coronary artery) or reversed flow through the bypass, as a result of the narrowing of the proximal part of the left subclavian artery. In most cases the symptoms are stable and chronic, but in some patients an acute coronary syndrome can develop. Additionally, there are usually disturbances of the left upper limb perfusion. Routine blood pressure measurement on both arms is believed to identify a group of patients with high probability of subclavian artery stenosis, who may benefit from supplementation of coronary angiography with aortic arch imaging. Traditional surgical methods of treatment for subclavian-coronary steal syndrome include bypass between the left common carotid and left subclavian artery. However, intravascular angioplasty with stent implantation is a contemporary method of choice. Intravascular methods allow simultaneous correction of coronary vessels when there is a recurrent stenosis.