Coronary subclavian steal syndrome after internal mammary artery bypass grafting. A cause of severe postoperative recurrent myocardial ischemia

A 65-year-old underwent a triple bypass: internal artery mammary-descending coronary artery, aorta diagonal-lateral coronary (sequential). Three weeks later he started to have severe angina pectoris with ST depression in anterior EKG leads. A left transradial coronary angiography was performed. The examination showed a total occlusion of the left subclavian artery 2 cm after the aortic arch and a retrograde flow in the internal mammary artery (IMA). Via transfemoral approach, angiography showed the patency of the aorto-veinous sequential graft and a retrograde flow through anastomosis in the left mammary artery. The patient underwent a reimplantation of the IMA on the brachiocephalic artery. One month later the patient is doing well without chest pain. A coronary subclavian steal syndrome should be suspected in case of recurrent ischaemia after IMA bypass, particularly if there is more than 20 mmHg systolic pressure differential between the arms. Left transradial approach achieved diagnostic in case of total left subclavian artery occlusion.