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(Circulation. 1998;97:1757.)
© 1998 American Heart Association, Inc.

Images in Cardiovascular Medicine

Coronary Artery Bypass Graft Surgery of 77-Year-Old Woman

Joseph A. Hill, Jr, MD, PhD; Dara Lee, MD; Peter Ganz, MD; Anthony D. Whittemore, MD; ; Patrick T. O'Gara, MD

From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115.

Correspondence to Joseph A. Hill, Jr, MD, PhD, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242-1081.

This 77-year-old woman underwent coronary artery bypass graft surgery, including the grafting of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) (Figure 1), 7 years before her current presentation with ischemic heart failure. She had previously been well except for an occasional feeling of left arm numbness.

View larger version (44K): [in this window] [in a new window]   Figure 1.

Her physical examination was notable for widespread vascular bruits and a 50 mm Hg difference in upper-extremity systolic blood pressures, right greater than left.

Diagnostic catheterization (JL4 catheter indicated by curved arrow, Figure 2) demonstrated retrograde filling of the LIMA through a highly diseased left main coronary artery and LAD (small arrows). The left subclavian artery was totally occluded proximal to the origin of the vertebral artery. The distal left subclavian artery filled via the LIMA, as did the left vertebral artery. A left common carotid–to–left subclavian artery bypass was performed to correct the subclavian steal and to restore anterograde LIMA flow.

View larger version (82K): [in this window] [in a new window]   Figure 2.

This case illustrates the importance of a careful evaluation of the peripheral arterial circulation in patients with ischemic heart disease.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.