Abstract
A 59-year-old woman with type 2 diabetes and two-vessel disease had undergone double coronary bypass grafting (CABG) five years previously, with left internal mammary artery (LIMA) to left anterior descending (LAD) artery and free radial graft (Y type), from LIMA to obtuse marginal (OM). Three months ago, the patient began to suffer angina and episodes of dizziness after upper limb exercise, followed by a lateral wall myocardial infarction one month ago. Urgent femoral catheterization revealed thrombotic occlusion of the circumflex (Cx) artery; the LAD had an old occlusion and the LIMA could not be catheterized. The right coronary artery (RCA) was normal. Primary angioplasty of the culprit Cx was performed and two bare-metal stents were deployed. The acute chest pain resolved, but angina and dyspnea recurred one week later. Physical examination revealed absent pulses in the left arm. Cardiac CT angiography revealed abrupt occlusion of the left subclavian artery 1.8 cm after its origin, proximal to the LIMA and the ipsilateral vertebral artery. Both these arteries supplied a scant flow to the axillary artery (Figures 1 and 2), but the LIMA
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