SHM Converge Scientific Abstract ePoster Gallery-Robbing the Heart and Brain: A Case of Coronary Subclavian Steal Syndrome

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This case describes a 70-year-old man with extensive cardiovascular and cerebrovascular disease who presented with 8 months of progressive dizziness and severe symptomatic hypotension. Despite fluid resuscitation, his blood pressure remained in the 60–70s/40–50s, prompting ICU admission and vasopressor support. His history included coronary artery disease status post 3-vessel CABG using a LIMA graft, peripheral arterial disease, prior CVA/TIA with seizures, chronic right internal carotid occlusion, moderate left carotid stenosis, hypertension, hyperlipidemia, COPD, and obstructive sleep apnea.<br /><br />Initial evaluation showed diffuse diminished pulses but no focal exam findings. Troponin was mildly elevated but downtrended, EKG showed normal sinus rhythm without ischemic changes, and chest X-ray showed mild vascular prominence. CTA of the head and neck demonstrated severe bilateral proximal subclavian artery stenosis. Echocardiography revealed a markedly reduced ejection fraction of 20–25% with severe global hypokinesis. Left heart catheterization showed patent bypass grafts without graft stenosis, but identified severe left subclavian stenosis with a 60 mmHg gradient between central aortic and limb pressures.<br /><br />The patient was diagnosed with coronary subclavian steal syndrome (CSSS), a condition in which proximal subclavian artery stenosis causes retrograde flow through a LIMA graft, diverting blood away from the coronary circulation. This can overlap with subclavian steal syndrome, which affects vertebrobasilar circulation and can cause dizziness or syncope. Vascular surgery placed a left subclavian stent, and the patient’s dizziness resolved after treatment.<br /><br />This case highlights the importance of considering subclavian steal syndromes in patients with prior vascular disease and LIMA grafts who present with dizziness, syncope, chest pain, or heart failure symptoms. Imaging and awareness of a patient’s vascular anatomy are essential for diagnosis and individualized management.

Asset Subtitle

Brandon D. Muckley

Meta Tag

Author List Akshay Chandora, Brandi Campbell, Brandon D. Muckley, Ufuoma Agbediaejughemre

Category Clinical Vignettes

Concept Subclavian Steal Syndrome

Concept Coronary Subclavian Steal Syndrome

Concept Subclavian Artery Stenosis

Concept Retrograde Flow

Concept Left Internal Mammary Artery Graft

Distinguished Non-Finalist

Presenter Organization Emory School of Medicine Division of Hospital Medicine

Presenting Author Brandon D. Muckley

Track Adult

Keywords

coronary subclavian steal syndrome

subclavian artery stenosis

LIMA graft

dizziness

hypotension

carotid stenosis

coronary artery disease

vascular disease

subclavian stent

retrograde flow

Subclavian Steal Syndrome

Coronary Subclavian Steal Syndrome

Subclavian Artery Stenosis

Retrograde Flow

Left Internal Mammary Artery Graft