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Endoluminal stenting of the subclavian artery to treat a surgically created left main equivalent lesion

The use of the left internal mammary artery (LIMA) during coronary bypass surgery is associated with excellent long-term graft patency, reducing the risk of recurrent angina, late myocardial infarction, and death [1,2]. The long-term results of saphenous vein bypass grafts, however, remain a significant limitation of coronary surgery, with reported 10-year patency rates of only 50– 60% [3,4]. Complete arterial revascularization by proximal anastomosis of the radial artery to the side of the left internal mammary artery in a T-graft configuration has been proposed by some as a way of avoiding the use of saphenous vein bypass graft [5]. This procedure makes the entire revascularization dependent on the patency of the proximal internal mammary artery. A significant left subclavian artery stenosis proximal to the origin of the left internal mammary artery could also result in impaired flow through the left internal mammary artery and hence cause coronary steal and angina. We report a patient with severe left main disease who underwent urgent coronary bypass surgery with total arterial revascularization using the left internal mammary artery to the left anterior descending artery and radial artery T-graft anastomosis to the diagonal artery and the left circumflex system. His postoperative course was uneventful and was discharged home on the fourth postoperative day. The patient presented 2 months after bypass surgery with unstable angina and was found to have a severe stenosis in the left subclavian artery proximal to the origin of the left internal mammary artery. The subclavian lesion, which had become a left main equivalent, was successfully treated with stent implantation.