Subclavian-coronary steal through a LIMA-to-LAD bypass graft

Eighteen months after coronary artery bypass grafting with a left internal mammary artery (LIMA) graft, a 58-year-old woman had a change in the character of her angina to include pain in the left arm, especially with upper extremity work, culminating in an episode of prolonged rest pain. Cardiac catheterization revealed retrograde flow through the LIMA graft to the subclavian artery and stenosis of the left subclavian artery at its origin from the aorta. Restoration of antegrade flow through the LIMA graft to the coronary arteries was achieved by a carotid-subclavian bypass resulting in a resolution of symptoms. The evaluation of recurrent angina after LIMA bypass grafting should exclude the possibility of subclavian artery stenosis as well as disease of the native and graft coronary anatomy.