Successful Management of Subclavian-Coronary Steal Through a LIMA-to-LAD Bypass Graft
Saturday, September 19, 2020
9:00 AM – 11:00 AM
Overview: It is generally challenging to figure out the source of ischemia in patients with previous by-pass surgery since the blood supply of the heart had been rearranged. Occlusion of grafts and/or non-grafted native vessels are the most common scenarios in the presence of documented ischemia. However in some instances, no obstructive lesion can be detected in grafts and native coronary arteries. Herein we present a case of successful management of subclavian stenosis causing ischemia in the anterior wall. A 68 years old male with previous by-pass surgery presented with stable angina and underwent myocardial perfusion scintigraphy. Ischemia was detected in the anterior wall and the patient was scheduled for coronary angiography. The native LAD was totally occluded and the LIMA-LAD graft was patent. However there was severe obstruction in the proksimal subclavian artery. A 6F sheath was inserted to left brachial artery and an additional 6F JR diagnostic catheter was advanced in order to display subclavian artery during the procudure. A 5 x 40 mm balloon was advanced through 6F JR guiding catheter and inflated at 10 atm. Then a 9 x 25 mm balloon expandable stent was deployed with minimal protrusion into the arcus aorta. The patient is free of symptoms since then. Briefly, not to overlook a subclavian obstruction in patients with previous by-pass surgery is of great importance even in the patients with severe obstruction in LIMA grafts. An endovascular non-coronary intervention can be required in the treatment of coronary ischemia. Balloon angioplasthy and/or stenting can be the first treatment option. To be familiar with peripheral interventions is of great importance.