Proximal Subclavian Artery Stenosis Diagnosis and Repair Documented by Both Myocardial Perfusion Imaging and Angiography
A 63-year-old man presented with a 3-month history of progressive angina relieved by rest. The chest pain worsened with exertion and radiated to his left arm. The use of his arms also exacerbated the pain. His medical history was significant for coronary artery disease, 4-vessel coronary artery bypass grafts (1997), mild hypertension, peripheral vascular disease, dyslipidemia, and type 2 diabetes mellitus. On admission, a 12-lead ECG and serial cardiac enzymes were negative for myocardial ischemia. An exercise thallium stress test demonstrated a large area of reversible ischemia in the anterior, septal, and apical walls (Figure 1). Subsequent cardiac catheterization surprisingly showed a widely patent left internal mammary artery and left anterior descending artery. The patient’s aortic blood pressure was 220/100 mm Hg, whereas the blood pressure in his left arm was normotensive. Angiography performed in the aortic arch and great vessels verified significant proximal left subclavian artery stenosis (Figure 2). After reviewing the benefits and risks with the patient, left subclavian artery angioplasty and stent intervention were performed (Figure 3). A repeat exercise thallium stress test performed 2 days after the intervention demonstrated complete resolution of the ischemia (Figure 4). Six weeks later, the patient remained free of angina and left arm claudication. A sonogram was performed and revealed the left subclavian artery stent to be widely patent.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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