the development of proximal subclavian stenosis may lead to reversal of flow from the left internal mammary artery ( lima ) to subclavian artery resulting in coronary artery disease known as coronary - subclavian steal syndrome ( csss ) . when feasible , subclavian angioplasty and/or stent placement can provide acceptable result for these patients . vascular reconstruction through carotid to subclavian artery bypass has been the standard procedure of choice . the use of lima is recommended as a coronary bypass graft due to its excellent long - term results . besides , csss might be seen depending on stenosis in proximal subclavian artery and escape of the flow back to the subclavian artery from lima . this case report describes the use of carotid - subclavian artery bypass for the treatment of csss . a 54-year - old male was admitted to our hospital with complaints of severe dyspnea , inability to lie in supine position , decrease in effort capacity , and pain in the left arm . physical examination revealed tachycardia and 3/6 apical systolic murmur ; bilateral rales in lower lung zones . brachial , axillary , and radial pulses of the left arm were not palpable but were clearly palpated over the right arm . past medical history revealed that he underwent coronary bypass graft operation five years prior to presentation . he was assessed to have new york heart association functional classification class iii - iv , with a clinical diagnosis of ischemic cardiomyopathy ( cmp ) , decompensated heart failure . an echoacradiogram was performed which showed increased left ventricular diameter and left ventricular ejection fraction of 18% by the modified simpson method . however , he continued to have symptoms of angina and left arm pain responsive to isosorbide dinitrate . a differential diagnosis of csss was considered and patient underwent coronary angiography . it was observed on coronary angiography that point of origin of the left subclavian artery in the aorta was totally congested beginning from approximately 1 cm proximal [ figure 1 ] . a vertebral artery angiography was showed subclavian in bridge collaterals and flow to lima were observed in late period . coronary - subclavian steal using a ringed polytetrafluoroethylene ( ptfe ) graft ( vascutek , germany ) with a diameter of 6 mm , a left carotid - subclavian bypass was performed on the patient in elective conditions . carotid shunt was not used while systemic heparin ( 5000 units ) was administered during the operation . postoperatively , a good graft pulse was felt in addition to easily palpable left upper extremity pulses . following the operation and in the postoperative period , the complaints of the patient related to chest pain , dyspnea , and left arm pain progressively decreased . control coronary - subclavian angiogram 1 month later revealed an intact ptfe graft between carotid and subclavian artery [ figure 2 ] . the coronary subclavian steal syndrome is an uncommon but well - recognized occurrence following coronary artery by - pass surgery using the internal mammary artery . in csss , the dilatation in the proximal region of the subclavian artery , depending on atherosclerosis in general , reduces lima blood flow and subsequently a back flow ( steal ) from the coronary artery to subclavian artery occurs . csss may develop quietly and also may cause angina , left arm ischemia , myocard infarction , and cardiac insufficiency . proximal aortic arch arteriography is the golden standard in the diagnosis of subclavian stenosis . alternatively , endovascular stent and balloon might be performed radiologically , whereas carotid - subcalvian and subclavian - subclavian bypass operations might be performed surgically . there are situations where several of these treatments could be applied in a combined manner . although the treatment methods applied radiologically has advantages regarding short hospitalization period and patient comfort , attempt failure , insufficient flow , restenosis ( 40.7% in early period ) , and the frequency of a secondary operation required in early period constitutes the disadvantages . surgical methods are still preferred more commonly due to their easy application and good results . in 1994 , vitti , et al . , reported their experiences in extrathoracic reconstruction as a treatment for subclavian steal syndrome . the patency rates at 5 and 10 years for carotid - subclavian bypass were about 94% , which compares favorably with the 66 - 89% patency rates for axilloaxillary bypass surgery . although carotid - subclavian transposition has been reported to have a 7-year patency rate of 100% , the potential aggravation of coronary ischemia during the interruption to vertebral and internal mammary artery blood flow is an obstacle to the use of this option . in our case , the patient developed symptoms more than 5 years after coronary artery bypass graft ( cabg ) . since the stenosis was very close to the vertebral artery , there was a risk of occlusion during stenting . carotid - subclavian artery bypass is considered the standard surgical treatment for symptomatic occlusion of proximal subclavian artery . however , preparing an atherosclerotic subclavian artery in our patient for anastomosis was not feasible . in addition , exposure of the subclavian artery and bypass grafting to it through supraclavicular approach is not without technical difficulty , especially with the close proximity to important lymphatic channels and nerves . on the contrary , infraclavicular exposure of the axillary artery is a straightforward technique routinely performed by vascular surgeons and eliminates some of the potential risks of supraclavicular approach . csss should be considered in patients presenting with recurrent chest pains after cabg with in situ left internal mammary grafts . surgical extra - anatomical bypass is an effective method of treating this uncommon condition when percutoneous transluminal angioplasty is not possible . in experienced hands , carotid axillary artery bypass can be a feasible alternative when the traditional procedures are technically difficult .
coronary - subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery , causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass . in the present case 
 , we discussed the diagnosis and the treatment of coronary steal syndrome in a patient hospitalized due to decompensated cardiac insufficiency .