ABSTRACT
A 64-year-old man, presented with progressive angina and left arm claudication. He had undergone bypass surgery, including a left internal mammary artery (LIMA) to the left anterior descending artery (LAD), 10 years before admission. Physical examination was notable because of a 40 mmHg systolic blood pressure gradient in the left arm. The patient underwent cardiac catheterization and was found to have patent grafts. Cervicocerebral arch and carotid angiography demonstrated widely patent great vessels, except for an 80% stenosis of the proximal left subclavian artery; the left vertebral artery arose directly from the aorta. He subsequently underwent percutaneous transluminal angioplasty (PTA) of the subclavian artery (Figure 9.1) with a 8 mm × 4 cm balloon to 8 atm. Post-PTA angiography (Figure 9.2) demonstrated a widely patent vessel with what was thought to be a stable dissection. Five days later he developed acute left arm ischemia. Radial and brachial pulses were absent; there was no evidence of distal embolization. Following initiation of intravenous heparin, weak pulses returned in the left upper extremity.
