PMC9242785_01
Electrocardiogram. Electrocardiogram showed ST-segment depression in leads II, aVF, and V4-V6 and ST-segment elevation in lead aVR.
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Electrocardiography demonstrated ST-segment depression in leads II, aVF, and V4-V6 and ST-segment elevation in lead aVR (Figure 1).
Angiography. Coronary angiography showed severe stenosis with a calcified nodule (arrow) at the left main coronary bifurcation (a). Subclavian angiography revealed occlusion of the proximal subclavian artery (arrowhead) (b). A left internal mammary artery bypass to the left anterior descending coronary artery was patent (c). LAD: left anterior descending artery; LCX: left circumflex artery; LIMA: left internal mammary artery; LSA: left subclavian artery.
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Coronary angiography revealed severe stenosis with a calcified nodule at the left main bifurcation (Figure 2(a)). The proximal segment of the LSA was occluded (Figure 2(b)), although the LIMA bypass to the LAD was patent (Figure 2(c)).
Intravascular imaging and final coronary angiography. Intravascular ultrasonography after rotational atherectomy revealed the presence of a calcified nodule (asterisk) (a). Final coronary angiography revealed TIMI3 flow to the left circumflex coronary artery after deployment of a drug-eluting stent.
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IVUS catheter passage. IVUS images revealed a calcified nodule (Figure 3(a)). After additional balloon angioplasty with a 3.0 mm noncompliant balloon, a 3.5/28 mm sirolimus-eluting stent (Ultimaster, Terumo, Tokyo, Japan) was successfully implanted (Figure 3(b)).
Myocardial scintigraphy and contrast-enhanced CT. Stress myocardial scintigraphy 7 days after the PCI procedure showed anteroseptal ischemia (a). Contrast-enhanced CT confirmed left subclavian artery occlusion at the anastomosed site (arrow) (b). Stress myocardial scintigraphy 3 days after axillo-axillary artery bypass surgery revealed improvement of myocardial ischemia (c). Contrast-enhanced CT 21 days postoperatively showed patency of the bypass graft (d). LAD: left anterior descending artery; LIMA: left internal mammary artery; LSA: left subclavian artery.
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CSSS due to LSA occlusion. Contrast-enhanced CT visualized LSA occlusion at the anastomosed site (Figure 4(b)), suggesting procedural risk associated with endovascular treatment. Stress myocardial scintigraphy performed 3 days postoperatively showed an improvement in anteroseptal ischemia (Figure 4(c)). Contrast-enhanced CT performed 21 days postoperatively showed patency of the bypass graft (Figure 4(d)).