Successful stenting of total left subclavian artery occlusion post-coronary artery bypass graft surgery using dual left vertebral artery and left internal mammary artery protection

We report on a 68-year-old male patient (smoker, chronic obstructive pulmonary disease, diabetic for 25 years) who was admitted with acute pulmonary edema 5 months after undergoing coronary artery bypass grafting (left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior descending artery, and sequential saphenous vein graft to obtuse marginal artery). He had no cardiac enzyme leakage and his left ventricular ejection fraction was > 50% on 2-dimensional echocardiography. He proved to have total calcific left subclavian artery occlusion and retrograde flow in both his left internal mammary artery and his left vertebral artery upon left subclavian angiography performed through the left brachial approach. Angiographic vertebral and coronary-subclavian steals were both supported with clinical manifestations. The patient underwent successful stenting to his left subclavian artery using dual protection to his left vertebral artery with filter protection device and to his left internal mammary artery using simple balloon inflation at its mouth before and after each subclavian artery angioplasty step. Three months later, the patient was free from any cardiac or neurologic complaints.