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[Persistent angina pectoris in spite of successful myocardial revascularisation]
O Kohl1, M Grebe, H Hölschermann
1Medizinische Klinik I (Kardiologie und Angiologie) der Universität Giessen, Klinikstrasse 36, 35392 Giessen, Germany. okohl@t-online.de
Insights
Persistent angina after coronary artery bypass grafting may indicate subclavian artery stenosis. Prompt blood pressure measurement in both arms is crucial for diagnosing this condition and resolving symptoms.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Vascular Medicine
Background:
- A 73-year-old obese female patient with coronary artery disease underwent coronary artery bypass grafting (CABG) and subsequent balloon angioplasty.
- The patient experienced recurrent angina pectoris, initially suspected as restenosis post-procedures.
Observation:
- Physical examination revealed significant blood pressure discrepancy between arms (160/80 mmHg right vs. 120/80 mmHg left).
- Duplex sonography identified severe plaques and reduced flow in the left vertebral artery, with post-stenotic flow in the left subclavian artery.
- Persistent angina symptoms post-right coronary artery intervention suggested an alternative diagnosis.
Findings:
- Coronarography confirmed a 70% stenosis in the left subclavian artery, leading to a marked coronary-steal syndrome.
- Successful balloon-dilatation and stent-implantation of the subclavian stenosis resolved the patient's angina pectoris.
Implications:
- Coronary-steal syndrome due to subclavian artery stenosis can mimic or cause persistent angina after successful CABG.
- Measuring blood pressure in both arms is essential for identifying subclavian artery stenosis, a critical step in diagnosing refractory angina.
Abstract:
A 73-year-old obese woman underwent coronary artery-bypass operation in 11/1995 because of a coronary two vessel disease. The left coronary artery was bypassed by the left mammarial internal artery. In 2 and 3/2002, balloon-dilatation of stenoses of the right coronary artery and the circumflex was performed. Angina pectoris relapsed and in 9/2002 the patient was admitted to our hospital with tentative diagnosis of restenosis. Physical investigation showed a blood pressure of the right arm of 160/80 and of the left arm of 120/ 80 mmHg. Coronarography showed the three vessel disease known since 2/2002 with a restenosis of the right coronary artery which was immediately treated by balloon-dilatation and stent-implantation. Colour duplex-sonography of the carotid and subclavian arteries revealed extraordinary plaques and a reduced flow of the left vertebral artery. The left subclavian artery could only be seen distal to the discharge of the vertebral artery and showed a poststenotic flow. The patient had angina pectoris when carrying out personal hygiene already 2 days after balloon-dilatation and stent-implantation. ECG showed new aspects. Coronarography showed no relapse of stenosis, but 70% stenosis of the left subclavian artery with a marked coronary-steal-syndrome. In 10/ 2002, the patient underwent balloon-dilatation and stent-implantation of the subclavian stenosis and became free of complaints. Coronary-steal-syndrome can be the reason for persistent angina pectoris in spite of successful coronary artery-bypass operation with a mammarial internal bypass. It is absolutely necessary to take blood pressure from both arms to recognise a possible stenosis of the subclavian artery which can be the key to all.