Purpose. Coronary-subclavian steal syndrome (CSSS) is defined as a reversal of flow in a previously constructed internal mammary artery (IMA) coronary conduit, producing myocardial ischemia. We present a case of CSSS which could not be ameliorated with endovascular therapy and necessitated a subclavian-subclavian bypass. Case Report. 80-year-old Caucasian male with history of CABG presented with syncope. He had absent left-sided radial pulse with blood pressure being 60/40 on left arm and 130/80 on the right. He underwent cardiac catheterization for NSTEMI which showed patent left internal mammary artery graft to left anterior descending coronary artery with retrograde flow, and diagnosis of coronary subclavian steal syndrome was made. Complete occlusion of proximal left subclavian artery was identified. Percutaneous angioplasty failed because of calcified plaque causing 100% occlusion. Carotid doppler showed bilateral carotid artery disease. He finally underwent subclavian-subclavian bypass which resolved his condition. Conclusion. Subclavian-subclavian bypass is a successful alternative to carotid-subclavian bypass for management of CSSS especially with concomitant critical carotid artery atherosclerotic disease. 1. Introduction Coronary-subclavian steal syndrome (CSSS) is defined as a reversal of flow in a previously constructed internal mammary artery (IMA) coronary conduit, producing myocardial ischemia. This is typically caused by proximal subclavian artery stenosis in patients with an ipsilateral IMA coronary conduit . This condition may have broad spectrum of symptoms related to alteration in flow in coronary circuit as well as changes in cerebrovascular hemodynamics. Posterior cerebral circulation  can be adversely affected as well as the ipsilateral brachial artery. CSSS may be treated endoscopically with stents if the lesion can be ameliorated, otherwise surgery is required which may include aortosubclavian bypass , carotid subclavian bypass , or axilloaxillary  bypass techniques. We are presenting a case which had an unusual presentation of CSSS, denied any chest pains to the presenting physician, and had mainly syncopal symptoms. He had a complicated hospital course limiting his medical management but finally had a successful subclavian-subclavian bypass. 2. Case Report An 80-year-old Caucasian male with history of coronary artery bypass graft (CABG) was brought to emergency room (ER) after being found unconscious at home. Detailed examination showed that left radial pulse was markedly diminished compared to right side and
P. S. K. Paty, M. Mehta, R. C. Darling III et al., “Surgical treatment of coronary subclavian steal syndrome with carotid subclavian bypass,” Annals of Vascular Surgery, vol. 17, no. 1, pp. 22–26, 2003.