Case report
An unusual cause of ischemia after coronary bypass grafting!!
Uma causa rara de isquemia após revascularização cirúrgica!!
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Martins, Vincent Auffret, Marc Bedossa" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Arnaud" "apellidos" => "Hubert" ] 1 => array:2 [ "nombre" => "Pierre" "apellidos" => "Guéret" ] 2 => array:2 [ "nombre" => "Guillaume" "apellidos" => "Leurent" ] 3 => array:2 [ "nombre" => "Raphael P." "apellidos" => "Martins" ] 4 => array:2 [ "nombre" => "Vincent" "apellidos" => "Auffret" ] 5 => array:2 [ "nombre" => "Marc" "apellidos" => "Bedossa" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918300199?idApp=UINPBA00004E" "url" => "/21742049/0000003700000001/v1_201802220457/S2174204918300199/v1_201802220457/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S217420491830014X" "issn" => "21742049" "doi" => "10.1016/j.repce.2018.02.001" "estado" => "S300" "fechaPublicacion" => "2018-01-01" "aid" => "1070" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2018;37:77-85" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1578 "formatos" => array:3 [ "EPUB" => 159 "HTML" => 1030 "PDF" => 389 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "Coronary artery disease in athletes: An adverse effect of intense exercise?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "77" "paginaFinal" => "85" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença coronária em atletas: «efeito adverso do exercício físico intenso?»" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1118 "Ancho" => 1503 "Tamanyo" => 75903 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hypothetical representation of the relationship between the dose of exercise and the incidence and severity of coronary artery disease. CAD: coronary artery disease.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Hélder Dores, Pedro de Araújo Gonçalves, Nuno Cardim, Nuno Neuparth" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Hélder" "apellidos" => "Dores" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "de Araújo Gonçalves" ] 2 => array:2 [ "nombre" => "Nuno" "apellidos" => "Cardim" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Neuparth" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491830014X?idApp=UINPBA00004E" "url" => "/21742049/0000003700000001/v1_201802220457/S217420491830014X/v1_201802220457/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "An unusual cause of ischemia after coronary bypass grafting!!" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "87.e1" "paginaFinal" => "87.e5" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Rania Hammami, Salma Charfeddine, Nizar Elleuch, Hela Fourati, Leila Abid, Samir Kammoun" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Rania" "apellidos" => "Hammami" "email" => array:1 [ 0 => "raniahammami@yahoo.fr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Salma" "apellidos" => "Charfeddine" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Nizar" "apellidos" => "Elleuch" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Hela" "apellidos" => "Fourati" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Leila" "apellidos" => "Abid" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Samir" "apellidos" => "Kammoun" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hedi Chaker Hospital, Cardiology Department, Sfax, Tunisia" "etiqueta" => "a" "identificador" => "aff0010" ] 1 => array:3 [ "entidad" => "Habib Bourguiba Hospital, Vascular Surgery Department, Sfax, Tunisia" "etiqueta" => "b" "identificador" => "aff0015" ] 2 => array:3 [ "entidad" => "Hedi Chaker Hospital, Radiology Departement, Sfax, Tunisia" "etiqueta" => "c" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Uma causa rara de isquemia após revascularização cirúrgica!!" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1330 "Ancho" => 1544 "Tamanyo" => 169451 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Sub-occlusive stenosis of left subclavian artery on angiogram. (B) CT angiography of supra-aortic vessels shows sub-occlusive and calcified stenosis of the subclavian artery ostium with heavy calcification of the aorta.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Angina recurrence in a patient after coronary artery bypass grafting (CABG) is usually attributed to graft dysfunction; coronary subclavian steal syndrome (CSSS) is rarely mentioned. CSSS is defined by retrograde blood flow from the left internal mammary artery (LIMA) into the subclavian artery (SCA); it is related to proximal stenosis or total occlusion of the SCA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> CSSS is not only difficult to diagnose but tricky to manage. Redux surgery is high risk in such patients and percutaneous treatment is sometimes made difficult by the angiographic appearance of the lesion. We report a case of CSSS and discuss diagnosis difficulties and management pitfalls.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">Mr. M.K is a 55-year-old man with a medical history of hypertension, dyslipidemia, smoking, mild chronic renal disease and peripheral artery disease. In 2010, he had CABG of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and a venous graft (VG) to the marginal. He remained asymptomatic for 6 years. Recently he developed chest pain on exertion, limiting his daily activities. He reported no other symptoms such as left arm claudication, paresthesia or dizziness. Physical examination was unremarkable, except for a difference in blood pressure between arms; left-arm pressure was 120/80 mmHg and right-arm pressure 140/80 mmHg. Left radial and brachial pulses were markedly reduced but we did not detect any abnormal murmur in the subclavian area. Electrocardiogram showed negative T waves in anterior leads. Echocardiography revealed a low left ventricular ejection fraction (LVEF=35%) with an anterior hypokinesia. Positron emission tomography (PET) showed anterior ischemia and inferior necrosis. A coronary angiogram was performed with initial right femoral access, showing a long severe stenosis in the LAD with competitive flow in the distal LAD and chronic total occlusions of the RCA and the first marginal. The saphenous-vein graft was also occluded. When trying to cannulate the LIMA, we failed to enter the subclavian artery. The aortogram revealed occlusion at the origin of the left SCA (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). We switched to left radial artery access; the LIMA was patent and free of stenosis. We decided to perform a transthoracic Doppler to check the flow in the LIMA, but the patient was lost to follow-up. Three months later, he returned with disabling angina. The transthoracic Doppler at that point showed retrograde flow in the LIMA, and confirmed CSSS. Computed tomographic angiography confirmed the presence of critical stenosis at the proximal SCA without any proximal stump (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>); the aorta/clavicle junction was heavily calcified and the left internal carotid was very narrow with an ostial atheroma. Fortunately, the left vertebral artery originated directly from the descending aorta (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). After multidisciplinary team discussion and given the risk of redux surgery in a such patient, we opted for endovascular management. The procedure was not easy given the angiographic aspects of the risk of calcium embolism, the difficulty crossing the lesion and the proximity to the carotid artery. However, the vertebral artery originating from the descending aorta was a favorable factor for angioplasty.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We performed the angioplasty of the SCA via a retrograde access from the left radial artery. The crossing of the lesion was laborious; we used many wires and even coronary wires (Whisper MS, Pilot 150 and Miracle 4) (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Finally, a TIF Tip™ 0.018 Terumo Hydrophilic Guidewire was advanced through the catheter and the SCA occlusion was barely crossed, using a retrograde subintimal dissection. Predilation using a coaxial balloon (Admiral Xtreme, Medtronic, 4×40 mm) was performed to the nominal diameter after confirming the intravascular position (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Next, a balloon expandable stent (6×37 mm) was inserted without complications. A final proximal optimizing post-stenting angioplasty was performed. The final angiography showed a good result with TIMI III flow in the LIMA (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Immediately after the procedure, the patient had a normal radial pulse. Six months later, his LVEF had improved (LVEF=45%).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nowadays, the LIMA graft is the most used as a result of the long-term patency and the low operative mortality rates.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> CSSS is an uncommon complication and has a low reported incidence (0.2% to 6.8%) after CABG surgery with the LIMA<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,3,4</span></a>; the first case was described in 1966.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> However, it seems to be underestimated and its incidence is currently rising as a result of the increasing use of the LIMA for CABG surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> CSSS is caused by stenosis or occlusion of the proximal SCA before the origin of the LIMA, resulting in reduced coronary flow and sometimes reversed flow. The consequence is myocardial ischemia.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> SCA stenosis may be present before CABG surgery or develop subsequently as a result of atherosclerotic disease progression.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Thereby, the ischemic symptoms can develop immediately following the CABG surgery or up to 7-8 years later.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> It is typically associated with signs of vertebrobasilar insufficiency.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Physical examination can reveal asymmetric upper-limb pulses and pressures as in our case or abnormal murmur in the subclavian area. The association of recurrence of ischemic signs and asymmetric systolic pressure after CABG should be suggestive of CSSS. This case highlights the importance of a systematic routine preoperative screening of SCA stenosis before CABG with either the LIMA or the right internal mammary artery, particularly in patients with multiple cardiovascular risk factors. SCA stenosis is typically diagnosed using continuous-wave Doppler ultrasonography on the LIMA; it will show reversed flow. Computed tomography, magnetic resonance imaging or angiography can be used as confirmatory tests for any suspected cases of subclavian steal. The traditional treatment consisted of surgical revascularization with extra-thoracic carotid-subclavian, subclavian-to-subclavian or axillo-axillary bypass grafting.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> It was associated with excellent long-term patency and low mortality rates.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Currently, endovascular therapy including percutaneous transluminal subclavian artery angioplasty has emerged as a good alternative to surgery.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7,8</span></a> One of the largest studies including 170 patients who underwent stenting of subclavian or innominate arteries reported a technical success rate of 98.3%, with 99.4% for stenotic lesions and 90.5% for occlusions. There were no procedure-related deaths and one stroke (0.6%). At long-term follow-up, 82% of all treated patients remained asymptomatic with a primary patency of 83% and a secondary patency of 96%.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> The complication incidence is low but complications can be lethal; in a series of 10 patients reported by Faggioli et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> a SCA spiral dissection with LIMA occlusion occurred in one patient. Fortunately, the complication was resolved with prolonged ballooning of the SCA.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our case, angioplasty was technically difficult, mainly as a result of the lesion angulation, the ostial location, tortuosity and heavy calcification. Moreover, the RCA, the marginal coronary and the venous graft were all occluded, and compromising the flow in the LAD/LIMA vessels, the only patent coronary axis, could therefore be lethal. The procedure was performed via a retrograde transradial subintimal dissection approach. The treatment consisted of transluminal angioplasty with balloon expandable stent placement after gentle balloon predilation. Some specific technical features associated with the SCA angioplasty need to be considered. First of all, ultrasound guidance is sometimes required for radial or brachial artery access because of the reduced flow within the artery making palpation of the pulse impossible.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Secondly, SCA access can be through an anterograde femoral approach or a combined simultaneous anterograde and retrograde approach.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> In a recent report, Satti et al. described controlled subintimal access of SCA occlusion using anterograde or simultaneous anterograde and retrograde access, a wire escalation approach, and then balloon predilation only to the size required to advance the stent in order to minimize large dissection or vessel rupture.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> The need for distal embolic protection when these occlusions are reopened is subject to debate and has rarely been reported.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> The flow direction within the vertebral artery did not immediately change to antegrade but rather did so gradually over 20 seconds to several minutes; this delay in flow reversal therefore served as a protective mechanism against cerebral embolism during balloon angioplasty and direct stenting for SCA stenosis, and embolic protection may not be necessary. However, SCA stenting after predilation required distal embolic protection because the VA blood flow changed to the anterograde direction after predilation. In our case, the vertebral artery originated directly from the aortic arch and thus protected against embolism. However, it could exacerbate signs of myocardial ischemia as there is no substitution of the vertebral reversed flow.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Recurrence of angina in patients who have undergone CABG should alert us to suspect CSSS. Diagnosis can be made from physical examination by discovering basilar syndrome and, above all, asymmetric arm pressure. The association with abnormal origin of the vertebral artery is exceptional and it may modify the clinical presentation. Endovascular angioplasty has become the treatment of choice, but a thorough analysis of the angiographic lesion is essential.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres987386" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec954785" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres987387" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec954786" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-05" "fechaAceptado" => "2016-10-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec954785" "palabras" => array:4 [ 0 => "Angioplasty" 1 => "Subclavian steal syndrome" 2 => "Coronary artery graft" 3 => "Case report" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec954786" "palabras" => array:4 [ 0 => "Angioplastia" 1 => "Síndrome do roubo da subclávia" 2 => "Enxerto da artéria coronária" 3 => "Caso clínico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A síndrome de roubo da subclávia é uma causa incomum de recidiva de isquemia após a cirurgia de revascularização do miocárdio (CABG). A terapêutica endovascular da estenose ou oclusão da artéria subclávia é cada vez mais usada e parece oferecer uma opção segura e efetiva à revascularização cirúrgica. Apresentamos o caso de uma angina recorrente após CABG devida a estenose arterial crítica da subclávia. A origem anómala da artéria vertebral a partir da crossa da aorta favoreceu o tratamento endovascular. Discutimos as dificuldades diagnósticas e as dificuldades do tratamento da angioplastia da artéria subclávia durante essa síndrome.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1330 "Ancho" => 1544 "Tamanyo" => 169451 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Sub-occlusive stenosis of left subclavian artery on angiogram. (B) CT angiography of supra-aortic vessels shows sub-occlusive and calcified stenosis of the subclavian artery ostium with heavy calcification of the aorta.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 911 "Ancho" => 2000 "Tamanyo" => 202831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abnormal origin of the vertebral artery from the aortic arch.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1585 "Ancho" => 2333 "Tamanyo" => 269035 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(a) First we crossed the lesion in a false lumen with a stiff guidewire with retrograde dissection of the aorta, so we withdrew the guidewire; (b) Attempt to cross the lesion with a coronary guidewire (Miracle 6); (c) Predilation of the lesion after the positioning of a TIF Tip™ 0.018 Terumo Hydrophilic Guidewire in subintima; (d) Release of the stent at the stenosis of the subclavian artery with 1 cm into the aorta; (e) Postdilation of the stent; (f) Final result with no residual stenosis and TIMI III flow of left internal mammary artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary subclavian steal syndrome and acute anterior myocardial infarction: a new treatment dilemma in the era of primary percutaneous coronary intervention" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 3 | 14 |
| 2024 October | 36 | 28 | 64 |
| 2024 September | 41 | 21 | 62 |
| 2024 August | 40 | 26 | 66 |
| 2024 July | 30 | 28 | 58 |
| 2024 June | 41 | 19 | 60 |
| 2024 May | 41 | 24 | 65 |
| 2024 April | 42 | 29 | 71 |
| 2024 March | 35 | 24 | 59 |
| 2024 February | 37 | 18 | 55 |
| 2024 January | 30 | 14 | 44 |
| 2023 December | 37 | 28 | 65 |
| 2023 November | 38 | 19 | 57 |
| 2023 October | 42 | 16 | 58 |
| 2023 September | 34 | 22 | 56 |
| 2023 August | 42 | 13 | 55 |
| 2023 July | 46 | 6 | 52 |
| 2023 June | 34 | 10 | 44 |
| 2023 May | 47 | 26 | 73 |
| 2023 April | 34 | 5 | 39 |
| 2023 March | 69 | 23 | 92 |
| 2023 February | 48 | 15 | 63 |
| 2023 January | 38 | 22 | 60 |
| 2022 December | 66 | 17 | 83 |
| 2022 November | 68 | 23 | 91 |
| 2022 October | 67 | 35 | 102 |
| 2022 September | 37 | 33 | 70 |
| 2022 August | 37 | 27 | 64 |
| 2022 July | 39 | 37 | 76 |
| 2022 June | 39 | 35 | 74 |
| 2022 May | 35 | 22 | 57 |
| 2022 April | 42 | 36 | 78 |
| 2022 March | 30 | 41 | 71 |
| 2022 February | 60 | 34 | 94 |
| 2022 January | 46 | 23 | 69 |
| 2021 December | 38 | 30 | 68 |
| 2021 November | 40 | 33 | 73 |
| 2021 October | 52 | 48 | 100 |
| 2021 September | 26 | 21 | 47 |
| 2021 August | 24 | 40 | 64 |
| 2021 July | 21 | 29 | 50 |
| 2021 June | 29 | 16 | 45 |
| 2021 May | 31 | 34 | 65 |
| 2021 April | 47 | 59 | 106 |
| 2021 March | 40 | 17 | 57 |
| 2021 February | 44 | 23 | 67 |
| 2021 January | 26 | 13 | 39 |
| 2020 December | 26 | 11 | 37 |
| 2020 November | 31 | 18 | 49 |
| 2020 October | 21 | 10 | 31 |
| 2020 September | 55 | 15 | 70 |
| 2020 August | 29 | 8 | 37 |
| 2020 July | 48 | 8 | 56 |
| 2020 June | 47 | 9 | 56 |
| 2020 May | 34 | 7 | 41 |
| 2020 April | 23 | 9 | 32 |
| 2020 March | 33 | 11 | 44 |
| 2020 February | 54 | 25 | 79 |
| 2020 January | 34 | 5 | 39 |
| 2019 December | 41 | 8 | 49 |
| 2019 November | 34 | 6 | 40 |
| 2019 October | 41 | 5 | 46 |
| 2019 September | 17 | 9 | 26 |
| 2019 August | 16 | 7 | 23 |
| 2019 July | 32 | 8 | 40 |
| 2019 June | 33 | 11 | 44 |
| 2019 May | 22 | 6 | 28 |
| 2019 April | 25 | 14 | 39 |
| 2019 March | 67 | 13 | 80 |
| 2019 February | 34 | 5 | 39 |
| 2019 January | 23 | 10 | 33 |
| 2018 December | 33 | 11 | 44 |
| 2018 November | 67 | 15 | 82 |
| 2018 October | 130 | 14 | 144 |
| 2018 September | 28 | 11 | 39 |
| 2018 August | 22 | 1 | 23 |
| 2018 July | 13 | 3 | 16 |
| 2018 June | 26 | 3 | 29 |
| 2018 May | 22 | 6 | 28 |
| 2018 April | 30 | 2 | 32 |
| 2018 March | 105 | 25 | 130 |
| 2018 February | 16 | 6 | 22 |
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