Vessel Update: sUbclaVian

28 Endovascular Today junE 2012 P roximal subclavian artery occlusive disease is a fairly common, usually asymptomatic, phenomenon.1 When patients become symptomatic, they can present with subclavian steal syndrome, or after coronary artery bypass grafting (CABG), coronary subclavian steal syndrome. Both syndromes share similar pathophysiology, diagnostic criteria, and management. The presentation of subclavian steal versus coronary subclavian steal varies noticeably. In classic subclavian steal, patients can exhibit symptoms of posterior cerebral ischemia, such as syncope, ataxia, vertigo, and/or dizziness.2-5 Patients may also present with signs and symptoms of upper extremity ischemia including claudication, rest pain, or tissue loss.3,5 Patients experiencing coronary subclavian steal might present with symptoms of cardiac ischemia such as chest pain or demonstrate ischemic changes during stress testing in the region of the heart supplied by the internal mammary artery (IMA).6 These patients may also demonstrate the symptoms of upper extremity ischemia that were previously mentioned. CASE REPORT An 87-year-old woman initially presented to the hospital with symptoms of nausea and left shoulder pain. The patient’s medical history was significant for hypertension, hyperlipidemia, peripheral arterial disease (PAD), and insulin-dependent diabetes mellitus. The patient was found to have a non-ST elevated myocardial infarction. Upon further workup, cardiac catheterization demonstrated significant triple-vessel disease (Figures 1 and 2). The patient underwent CABG surgery with a left IMA to left anterior descending artery, a saphenous vein to first obtuse marginal artery, and a saphenous vein to posterior descending artery anastomoses. The patient had a fairly uncomplicated postoperative course. One year after surgery, the patient presented to the hospital after a witnessed syncopal episode. The syncope workup included a carotid duplex ultrasound, which showed 60% to 79% stenosis of the right common carotid artery, 80% to 89% stenosis of the left common a look at Proximal subclavian artery occlusive disease