Associazione Nazionale Medici Cardiologi Ospedalieri



Acute Coronary Syndrome in a patient with left subclavian occlusion and anterolateral coronary steal.

Biancofiore Antonio Grosseto(Grosseto) – Ospedale Misericordia | Filippi Federico Grosseto(Grosseto) – Ospedale Misericordia | Pieraccini Massimo Grosseto(Grosseto) – Ospedale Misericordia

This is a 57-year-old male patient suffering from multiple cardiovascular risk factors: obesity, arterial hypertension, dyslipidemia, type 2 diabetes mellitus, active smoker. Chronic obstructive pulmonary disease. Stage 2 chronic kidney disease. Peripheral vascular disease with previous bilateral thromboendarterectomy and percutaneous revascularization of the lower limbs. Stable angina for which three years ago he underwent Coronary Artery Bypass Graft: left internal mammary artery (LIMA) to left anterior descending artery combined with saphenous vein grafts to the main obtuse marginal branch.

The patient presented with Acute Coronary Syndrome non ST-segment elevation myocardial infarction (N-STEMI), intermittent episodes of chest pain due to mild exertion in the previous days. Antero-lateral ST depression and inverted T waves, associated with a mild reduction in left ventricular systolic function due to hypokinesia of the antero-lateral walls and increased troponin values were present.

Coronary angiography documented patency of the LIMA graft without evidence of any culprit lesions on the coronary branches. However, selective angiography documented a sub-occlusion of the proximal left subclavian artery (Figure 1). A computed tomography scan confirmed a hyperdense calcified plaque occluding 95% of the origin of the left subclavian artery. The patient then underwent angioplasty with stenting of the left subclavian artery (Figure 2).

Subclavian coronary steal syndrome usually presents with exertional angina, but rarely can cause Acute Coronary Syndrome. During coronary angiography performed for Acute Coronary Syndrome and in the absence of detection of clear coronary culprit lesions, selective angiography of the subclavian artery may confirm the suspicion of coronary steal syndrome.