Looking Beyond the Coronaries

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  Figure 1. Acute Subclavian Occlusion as a Cause of Myocardial Ischemia in LIMA-Dependent Circulation In patients with prior LIMA-to–left anterior descending artery LAD bypass grafting, acute thrombotic occlusion of the proximal left subclavian artery may abruptly interrupt inflow to the LIMA conduit, resulting in myocardial ischemia, ventricular arrhythmias, or hemodynamic collapse. Recognition of this mechanism requires a diagnostic approach that extends beyond the coronary arteries to include proximal subclavian evaluation. Endovascular treatment with covered stent implantation may restore antegrade flow, preserve the vertebral and LIMA origins, and reverse ischemia. CABG = coronary artery bypass grafting; CT = computed tomography; LAD = left anterior descending artery; LIMA = left internal mammary artery.