Subclavian Artery Disease

This 55 year old man underwent 4 vessel bypass surgery for left main disease 6 weeks before developing exertional left sided chest pain during cardiac rehabilitation. Nuclear stress testing showed equivocal ECG changes but there was a significant thallium abnormality limited to the anterior wall. Diagnostic cardiac catheterization was then performed showing patency of the 3 vein grafts and no significant changes in the native coronary circulation. However, passage of a catheter into the left subclavian was extremely difficult due to severe atherosclerosis of the subclavian artery shown above left. The diagnosis was ischemia to the anterior wall due to subclavian artery disease which was limiting flow into the internal mammary artery resulting in hypoperfusion to the LAD. He described no pain in the left arm but the left radial pulse was mildly decreased. There was no clear history of drop-attacks or subclavian steal although in retrospect he reported mild exertional dizziness.

The Subclavian artery disease was successfully treated non-surgically. The lesion in the subclavian artery was treated with implantation of a Palmaz balloon expandable stent through an 8F 90 cm sheath after wiring the lesion with a 0.035 wire and predilating with balloon catheter.

The patient tolerated the procedure without problems and was discharged the following morning. Follow-up stress testing 2 weeks later showed no evidence of anterior wall ischemia and he successfully completed cardiac rehab without further symptoms.