Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Post–coronary artery bypass grafting (CABG) using an internal thoracic artery pedicle graft Angina with unilateral arm exercise Subclavian artery stenosis demonstrated by imaging, proximal to the internal thoracic artery used for the coronary graft in the affected upper limb +++ GENERAL CONSIDERATIONS ++ The internal thoracic artery is the preferred conduit for proximal left anterior descending CABG because of its relative resistance to atherosclerosis and demonstrated excellent long-term patency Unfortunately, the subclavian artery, from which the internal thoracic is a branch, is a common site of atherosclerotic plaque build-up When the subclavian is obstructed proximal to the origin of the internal thoracic, coronary blood flow can be compromised, especially during arm exercise (coronary steal) +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Angina pectoris with unilateral arm exercise Vertebrobasilar symptoms with unilateral arm exercise +++ PHYSICAL EXAM FINDINGS ++ > 20 mm Hg difference in systolic blood pressure between right and left arm Reduced pulse in affected arm +++ DIFFERENTIAL DIAGNOSIS ++ Progressive native coronary artery disease Technical problems with the internal thoracic artery graft Disease in vein grafts to other coronary arteries +++ DIAGNOSTIC EVALUATION +++ ELECTROCARDIOGRAPHY ++ ST-T changes of ischemia +++ IMAGING STUDIES ++ Stress myocardial imaging demonstrates ischemia +++ DIAGNOSTIC PROCEDURES ++ Catheterization and angiography demonstrate the subclavian obstruction proximal to the internal thoracic artery origin +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Recurrent angina after bypass surgery +++ HOSPITALIZATION CRITERIA ++ Acute coronary syndrome Significant resting arm ischemia (rare) +++ MEDICATIONS ++ Standard antianginal drugs +++ THERAPEUTIC PROCEDURES ++ Angioplasty and stenting of the subclavian artery +++ SURGERY ++ Extrathoracic surgical approach: – Conduit from carotid to the subclavian distal to the stenosis or distal subclavian to carotid anastomosis Intrathoracic surgical approach: – Subclavian endarterectomy or aortosubclavian grafting +++ MONITORING ++ ECG monitoring in hospital as appropriate +++ DIET AND ACTIVITY ++ Restrict arm exercise until problem corrected Low-fat diet +++ ONGOING MANAGEMENT +++ HOSPITAL DISCHARGE CRITERIA ++ Resolution of symptoms After successful procedure or surgery +++ FOLLOW-UP ++ Three months, 6 months, then yearly if stable +++ COMPLICATIONS ++ Ischemic digits due to emboli Myocardial infarction +++ PROGNOSIS ++ Good, with correction of subclavian ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.