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Vol. 41. Núm. 4.
Páginas 353-354 (Abril 2022)
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Vol. 41. Núm. 4.
Páginas 353-354 (Abril 2022)
Image in Cardiology
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Angina pectoris in a patient with prior coronary artery bypass graft and carotid-subclavian bypass grafting
Angina pectoris num doente com cirurgia de revascularização miocárdica prévia e bypass carótido-subclávio
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...
Mehmet Rasih Sonsoz
Autor para correspondência
mrsonsoz@gmail.com

Corresponding author.
, Aslan Erdogan, Ersin Ibisoglu, Ayse Irem Demirtola, Fatih Uzun
Department of Cardiology, Basaksehir Cam & Sakura City Hospital, Istanbul, Turkey
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A 51-year-old man was admitted with exertional chest pain. Eleven years ago, he underwent myocardial revascularization consisting of a left internal mammary artery (LIMA) graft to the first diagonal artery. Seven years ago, he underwent carotid-subclavian bypass surgery due to subclavian artery stenosis. After the second surgery, he was stable, but he developed exertional chest pain last year. His physical examination was remarkable for the presence of weak left radial and brachial pulses, with a significant difference in blood pressure between the right (130/85 mmHg) and left (90/60 mmHg) arms. Electrocardiogram showed normal sinus rhythm without ischemic changes. Contrast injection into the left main coronary artery showed chronic total occlusion of the circumflex artery and demonstrated a striking retrograde flow from the coronary tree through the graft (Figure A; Video 1). A left subclavian artery angiography revealed total occlusion proximal to the origin of the LIMA (Figure B; Video 2). A left common carotid artery angiography showed the total occlusion of the carotid-subclavian bypass graft (Figure C; Video 3). We decided on percutaneous intervention of the left subclavian artery, and the patient was successfully treated with subclavian balloon angioplasty and stent placement (Figure D; Video 4-8).

Figure.

A. Left coronary angiography showing retrograde flow from the coronary tree through the mammary artery bypass graft (arrow). B. Left subclavian angiography revealed total occlusion proximal to the left internal mammary artery graft to the first diagonal artery. C. Left common carotid angiography demonstrated the total occlusion of the carotid-subclavian bypass graft (arrow). D. Digital subtraction angiography of the left subclavian artery after stent placement showed successful treatment of the subclavian occlusion.

D1: first diagonal artery; LAD: left anterior descending artery; LCCA: left common carotid artery; SA: subclavian artery.

(0,23MB).

In this case, we illustrated coronary subclavian steal syndrome in a patient with prior coronary artery bypass graft (CABG) despite carotid-subclavian bypass grafting. Percutaneous intervention with stent implantation was successful. Angina pectoris and differential blood pressure readings in a patient with prior CABG should alert attending physicians to the possibility of this syndrome.

Conflicts of interest

The authors have no conflicts of interest to declare.

Appendix A
Supplementary material

The following are the supplementary material to this article:

(0,38MB)

Left coronary angiography showing retrograde flow from the coronary tree through the mammary artery bypass graft.

(0,42MB)

Left subclavian angiography showed total occlusion proximal to the left internal mammary artery graft to the first diagonal artery.

(0,27MB)

Left common carotid angiography revealed total occlusion of the carotid-subclavian bypass graft.

(0,18MB)

The total occlusion in the left subclavian artery was crossed with hydrophilic guidewire (Hi-torque Progress 140T, Abbott), and the lesion was predilated with a non-compliant coronary balloon (4.0×20 mm, Simpass).

(0,42MB)

The flow was restored after balloon angioplasty.

(0,13MB)

A peripheral stent was implanted distal to the lesion (7.0×27 mm, Boston Scientific Express LD Vascular).

(0,02MB)

Another peripheral stent was implanted proximal to the first stent (10.0×25 mm, Boston Scientific Express LD Vascular).

(0,5MB)

Digital subtraction angiography of the left subclavian artery after stent placement showed successful treatment of the subclavian occlusion.

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