A patient with multiple vascular atherosclerotic distributions

Area of Science:

• Cardiovascular Medicine
• Vascular Surgery
• Interventional Cardiology

Background:

• Coronary artery bypass grafting (CABG) using the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is a standard procedure.
• Patients with severe coronary artery disease (CAD) often have diffuse atherosclerotic disease affecting multiple vascular beds.

Observation:

• A patient presented with unstable angina late after LIMA-LAD bypass surgery.
• Catheterization revealed left main stem disease, a proximal left subclavian artery (SCA) lesion, and an abdominal aortic aneurysm, none of which were previously suspected.
• The patient experienced recurrent angina, pulmonary edema, and cardiac arrest, leading to death despite recommended combined surgical management.

Findings:

• Recurrent angina post-CABG, especially with LIMA grafts, should raise suspicion for coronary subclavian steal syndrome due to proximal SCA stenosis.
• Severe CAD increases the risk of coexisting vascular pathologies like SCA stenosis and abdominal aortic aneurysms.
• Undiagnosed SCA lesions and aneurysms can complicate management strategies for patients with coronary disease.

Implications:

• A comprehensive cardiovascular evaluation is essential for patients with severe CAD to identify extensive atherosclerotic disease.
• Early detection of multifocal atherosclerosis impacts interventional and surgical decision-making.
• This approach ensures the selection of the safest and most effective treatment strategy for complex cardiovascular patients.