Coronary subclavian steal syndrome after internal mammary artery bypass grafting: a cause of severe recurrent ischemia.

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