Coronary Subclavian Steal Syndrome and Acute Anterior Myocardial Infarction: A New Treatment Dilemma in the Era of Primary Percutaneous Coronary Intervention.

Abstract

Coronary subclavian steal syndrome (CSSS) is an uncommon complication after coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA).1–3 CSSS results from the retrograde blood flow through the LIMA graft in the left subclavian artery (SCA), consecutive to a proximal SCA stenosis or total occlusion. CSSS usually manifests as stable angina pectoris1 but also rarely presents as ST-segment–elevation myocardial infarction secondary to an acute SCA occlusion or plaque rupture.1,2 Anterior ST-segment–elevation myocardial infarction resulting from an acute thrombotic occlusion of the left anterior descending (LAD) artery at the LIMA-to-LAD anastomotic site in a patient with concomitant CSSS may be a challenging problem during primary percutaneous coronary intervention and has not been reported to date. Here, we report on a 62-year-old woman with hypertension, dyslipidemia, and peripheral artery disease who underwent CABG surgery using a LIMA graft to the LAD 12 years earlier (Figure 1 and Movie I in the online-only Data Supplement). The patient presented to the emergency department with de novo exertional chest pain. The 12-lead ECG showed negative T waves in the anterior leads, and her cardiac biomarkers were normal. During admission, the patient developed chest pain at rest associated with paresthesias of the left hand. An ECG showed new anterior ST-segment elevation, and the patient was transferred for primary percutaneous coronary intervention. The left coronary angiogram (Movie II in the online-only Data Supplement) showed a patent LAD with critical …