CA8 Subclavian artery restenosis causing coronary-subclavian steal syndrome. (Cardiology).

CA8 SUBCLAVIAN ARTERY RESTENOSIS CAUSING CORONARY-SUBCLAVIAN STEAL SYNDROME. Rajiv N. Thakkar, MD, Vaishali Popat-Thakkar, MD, MPH, and Flenry Meilman, MD. Union Memorial Hospital, Baltimore, Md.

A 47-year-old white woman with hypertension, hyperlipidemia, and smoking presented with retrosternal burning pain and exertional dyspnea for 1 year. Physical examination on admission was remarkable for blood pressure left arm 104/80 mm Hg, right arm 150/80 mm Hg, left carotid bruit, feeble left brachial and radial pulsation. Carotid duplex showed left carotid and left subclavian artery stenosis. Cardiac catheterization showed atherosclerotic disease in left main, left anterior descending (LAD), and right coronary artery (RCA) with normal ejection fraction. She had left subclavian stent and left carotid endarterectomy, followed by CABG tising left internal mammary artery (LIMA). Patient was asymptomatic for 3 years but later presented with anginal symptoms with left arm pain, and the stress test was positive. Cardiac catheterization showed patent RCA graft, 70% occluded LAD, occluded left subclavian stent with retrograde flow from LIMA to subclavian artery distal to restenosis. Successful arigioplasty with res tenting of left subclavian artery resulted in antegrade flow in LIMA, with majority of distal LAD filling through patent LIMA. This was followed by complete resolution of anginal symptoms and left arw pain. Although coronary-subclavian steal syndrome due to subclavian stenosis is an uncommon but known complication following CABG using LIMA, restenosis of stented subclavian artery is a rare cause of coronary-subclavian steal syndrome. Use of LIMA in myocardial revascularization is widely accepted, given its long-term patency rate and low incidence of atherosclerosis. Restenosis of subclavian artery stent causing anginal symptoms should always be considered in all stented patients. Routine screening test in the form of BP measurement in both arms and auscultation for carotid/subclavian bruit can help to prevent and diagnose this rare but potentially drastic complication before or after myocardial revascularization using LIMA. Routine angiography of carotid/subcalvian artery is not yet recommended. Angioplasty a nd stent placement remains an effective and safe treatment for subclavian artery restenosis causing coronary-subclavian steal syndrome.