Images in Cardiothoracic Medicine and Surgery
Subclavian steal syndrome in a post-coronary artery bypass patient
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 738–739 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313516963 aan.sagepub.com
Min Er Ching, Paul Jau Lueng Ong and Hee Hwa Ho
Figure 1. (A) Baseline myocardial perfusion scan (rest and stress images in short axis) showing a perfusion defect in the anterior wall (arrowheads). (B) Myocardial perfusion scan poststenting (rest and stress images in short axis) showing resolution of the perfusion defect in the anterior wall.
A 65-year-old man with history of coronary artery bypass grafting, presented with classic angina. A dipyridamole radionuclide myocardial perfusion scan demonstrated a large area of ischemia in the anterior wall and a medium-sized area of moderate ischemia in the inferior wall (Figure 1A). Coronary angiography revealed severe native triple-vessel disease. Both the native right coronary artery and the saphenous vein graft to the posterior descending artery were occluded. While attempting to selectively cannulate the left internal mammary artery, we encountered difficulty in advancing a 6F diagnostic catheter from the aortic
Figure 2. Angiography showing (A) a high-grade stenosis in the proximal segment of the left subclavian artery (arrowhead), and (B) the left subclavian artery after stenting.
arch into the left subclavian artery. Diagnostic angiography showed critical stenosis in the proximal segment of the subclavian artery (Figure 2A). We downsized to a 4F diagnostic catheter, and successfully cannulated the left internal mammary artery which was found to
Department of Cardiology, Tan Tock Seng Hospital, Singapore Corresponding author: Hee Hwa Ho, Department of Cardiology, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433 Email: [email protected]
Downloaded from aan.sagepub.com at City University Library on March 24, 2016
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be widely patent. A pressure gradient of 40 mm Hg was noted across the stenosis during pullback. The patient subsequently underwent successful angioplasty and stenting of the left subclavian artery (Figure 2B). He returned for follow-up with improvement in anginal symptoms. A repeat nuclear imaging scan demonstrated resolution of ischemia in the anterior wall (Figure 1B). Recurrent symptoms of angina following an otherwise successful coronary revascularization using a left internal mammary artery graft may indicate a hemodynamically significant proximal left subclavian stenosis. As illustrated by our case, we should be alert
to this possibility when a reversible perfusion defect is detected in the anterior wall on a myocardial perfusion scan. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
Downloaded from aan.sagepub.com at City University Library on March 24, 2016
Subclavian steal syndrome in a post-coronary artery bypass patient
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 738–739 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313516963 aan.sagepub.com
Min Er Ching, Paul Jau Lueng Ong and Hee Hwa Ho
Figure 1. (A) Baseline myocardial perfusion scan (rest and stress images in short axis) showing a perfusion defect in the anterior wall (arrowheads). (B) Myocardial perfusion scan poststenting (rest and stress images in short axis) showing resolution of the perfusion defect in the anterior wall.
A 65-year-old man with history of coronary artery bypass grafting, presented with classic angina. A dipyridamole radionuclide myocardial perfusion scan demonstrated a large area of ischemia in the anterior wall and a medium-sized area of moderate ischemia in the inferior wall (Figure 1A). Coronary angiography revealed severe native triple-vessel disease. Both the native right coronary artery and the saphenous vein graft to the posterior descending artery were occluded. While attempting to selectively cannulate the left internal mammary artery, we encountered difficulty in advancing a 6F diagnostic catheter from the aortic
Figure 2. Angiography showing (A) a high-grade stenosis in the proximal segment of the left subclavian artery (arrowhead), and (B) the left subclavian artery after stenting.
arch into the left subclavian artery. Diagnostic angiography showed critical stenosis in the proximal segment of the subclavian artery (Figure 2A). We downsized to a 4F diagnostic catheter, and successfully cannulated the left internal mammary artery which was found to
Department of Cardiology, Tan Tock Seng Hospital, Singapore Corresponding author: Hee Hwa Ho, Department of Cardiology, Tan Tock Seng Hospital, 11, Jalan Tan Tock Seng, Singapore 308433 Email: [email protected]
Downloaded from aan.sagepub.com at City University Library on March 24, 2016
Ching et al.
739
be widely patent. A pressure gradient of 40 mm Hg was noted across the stenosis during pullback. The patient subsequently underwent successful angioplasty and stenting of the left subclavian artery (Figure 2B). He returned for follow-up with improvement in anginal symptoms. A repeat nuclear imaging scan demonstrated resolution of ischemia in the anterior wall (Figure 1B). Recurrent symptoms of angina following an otherwise successful coronary revascularization using a left internal mammary artery graft may indicate a hemodynamically significant proximal left subclavian stenosis. As illustrated by our case, we should be alert
to this possibility when a reversible perfusion defect is detected in the anterior wall on a myocardial perfusion scan. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
Downloaded from aan.sagepub.com at City University Library on March 24, 2016
