Background
In patients who underwent coronary artery bypass graft (CABG), the coronary-subclavian steal syndrome (CSSS) is characterized by a subclavian artery stenosis (SAS) proximal to the origin of the internal mammary artery resulting in functional graft failure.
Case summary
A 62 year-old gentleman underwent CABG following a non ST Elevation Myocardial Infarction (NSTEMI) and an angiogram showing Left Main Stem (LMS) and three-vessel disease. 48 hours later he developed cardiogenic shock that improved with inotropic support and IABP insertion. However, seven days later, he deteriorated again and even though the myocardial injury markers and echocardiogram were normal, an angiography was performed showing significant CSSS. Due to the chronic nature of his subclavian stenosis and the severity of the cardiogenic shock, the heart team decided to treated his epicardial disease percutaneously and occlude the Left Internal Mammary Artery (LIMA) in its mid-segment with coils. The patient was discharged home 28 days after CABG and has remained since asymptomatic with improvement in his functional class.
Discussion
CSSS is a rare but fatal complication with increased morbidity and mortality due to reduced awareness amongst medical professionals. SAS stenting is the gold standard treatment; herein we present a new approach for complex and very sick patients in whom it is not possible to open the subclavian artery percutaneously. Increased awareness and prompt diagnosis of this pathology in CABG patients is essential for successful outcomes.