When a subclavian artery is equivalent to STEMI of left main coronary artery

Mohammed Saad (Kiel)1, A. Elhakim (Neustadt in Holstein)2, D. Frank (Kiel)1

1Universitätsklinikum Schleswig-Holstein Innere Medizin III mit den Schwerpunkten Kardiologie, Angiologie und internistische Intensivmedizin Kiel, Deutschland; 2Schön Klinik Neustadt Klink für Innere Medizin und Kardiologie Neustadt in Holstein, Deutschland


Clinical Presentation
•     Present history: 81 years old male patient presented with acute coronary syndrome with sever anginal pain for two hours
•     Past history: known ischemic heart disease, history of CABG for nine years(LIMA to LAD and Cx and venous graft to RCA)
•     CVRF: art. Hypertension, Hypercholestrinemia 

•          ECG: Sinus rythsm, ST-Elevation > 2 mV in V1-V6, I and AVL
•          Echocardiography: HFmEF ca. 45%
•          Lab.: leucocyte 7.5/ µl, hemoglobin 13 g/dl, thrombocyte 392.000/ µl, Trop 2400 ng/l, CK 240 U/I, NT-Pro-BNP 6544 pg/ml
•          Hemodynamic: cardiogenic shock, blood pressure of 
-   right upper extremity 90/65 mmHg 
-    left upper extremity 70/40 mmHg 

Coronary angiography via right femoral artery 

RCA venous graft: TIMI-Flow III
LCA:  chronic total occlusion  
Left subclavian artery: acute thrombotic proximal segmental occlusion before the origin of LIMA 

Percutaneous intervention of left subclavian artery 

- Successful implantation of self-expandable stent (Absolute Pro 7 x 60 mm, Abbott) in the proximal part and second Balloon expandable stent (Dynamic, 8x 39 mm, Biotronic) in the distal part prior to origin of LIMA
Immediate restoration of anterograde flow of the LIMA to left coronary circulation. 
Stabilization of hemodynamics and relive of symptoms.  

Technical considerations
•       The second stent was selected to be a Balloon expandable stent due to its better delivery profile and deployment precision. 
•       The size of subclavian artery was made by visual angiographic analysis, pre dilatation balloon, and was based on the nominal diameter of the target vessel, diameter proximal and distal to the lesion and the extension of it.
•       The benefits of screening patients referred for CABG for SAS are not known, and current guidelines fail to provide guidance about screening high-risk patients for this entity.

Technical considerations
•       Balloon-expandable stent is favored in the right subclavian artery facilitate precise deployment to avoid any obstruction of the right common carotid artery during implantation.
•       Both Balloon-expandable stents and self-expandable stents could be implanted in the left subclavian artery.
•       To minimize risk of distal embolization, some operators use a distal embolic protection device in the ipsilateral vertebral or carotid artery.
•       Extra-thoracic carotid-subclavian and axillary-axillary bypass should be considered, if percutaneous intervention failed.
•       An appropriate tool is essential and required in the cath lab to tackle unexpected scenario and complication of usual PCI.

Summary and take home
•          83 y Patient presented with cardiogenic shock due to anterior and lateral wall STEMI.
•          Previous history of CABG ( LIMA to LAD and Cx and venous graft tp RCA.
•          Coronary angiohgraphy: acute thrombotic occlusion of left subclavian artery 
•          PCI of left subclavian artery with both self-expandable and balloon expandable stents.
•          In CABG patients presenting with acute myocardial ischemia, extra care should be taken to the CSSS as a possible etiology. 
•          SAS imaging screening could improve management outcomes in high-risk patients. 
•          An appropriate tool is essential and required in the cath lab to tackle unexpected scenario and complication of usual PCI.
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