PMC9883703_01
Polar map images of myocardial perfusion at stress and at rest. A calculated polar map of perfusion reversibility. Reversible ischaemia in the left circumflex artery vascular region. Perfusion defect in the LAD supplied anterobasal region. No areas of significant perfusion deficiency at rest.
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Myocardial perfusion imaging with positron emission tomography (PET) (Figure 1) showed a perfusion defect.
Coronary angiography. (A) Right coronary artery remains clotted, with slow collateral inflow. (B) No stenosis in left main (LM) coronary artery, dominant branch of LM is left circumflex artery of and proximal narrowing in left obtuse marginal (LOM) artery, total blockage in LAD. (C) Plausible subclavian aneurysm is suggested by vessel lumen narrowing and turbulent flow in proximal left subclavian artery. Left internal mammary artery graft is open:no narrowing is visible proximally (C) or distally (D). Sternotomy fixation is visible in all projections.
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However, there was no significant stenosis visible in the left circumflex artery (LCX) in coronary angiography, and no suitable percutaneous coronary intervention (PCI) target could be identified (Figure 2).
Preoperative Doppler-ultrasound of the left vertebral artery. Flow is inverted during systole.
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Doppler ultrasound flow spectre in the left vertebral artery was inversed during systole (Figure 3), and distal LSA exhibited attenuated, collateral-type currents, as did the axillary and the radial arteries.
Computed tomography angiography; preoperative (A and B) and postoperative (C and D) 3D reconstructions (A and C) and key CT (B and D) images of the subclavian aneurysm and surrounding vascular structures. Bypass graft (k) is open and functioning in the postoperative images (C and D). e: subclavian aneurysm, f: distal subclavian artery, g: left vertebral artery, h: left internal mammary artery-LAD graft, i: left carotid artery, j: cross-sections of the aneurysm (1-4; superior to inferior slice), and k: carotid-subclavian bypass graft.
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Three months after the procedure, the bypass graft (Figure 4) LSA and vertebral artery showed regular contrast agent enhancement.