A patient with multiple vascular atherosclerotic distributions.

The present report describes a patient who experienced unstable angina late after coronary artery bypass surgery, in which the left internal mammary artery was grafted to the left anterior descending artery. Catheterization revealed the culprit, which was left main stem obstructive disease, a significant proximal left subclavian artery (SCA) lesion and a large abdominal aortic aneurysm. The latter lesions were not suspected or revealed before catheterization. Combined surgical management was recommended; however, the patient died following recurrent angina that was complicated with pulmonary edema and cardiac arrest. Patients with severe coronary artery disease are at high risk of having multiple vascular atherosclerotic distributions including SCA stenosis and abdominal aortic aneurysm. Recurrent angina after left internal mammary artery grafting should always raise the suspicion of a left SCA stenosis causing coronary subclavian steal. Such patients should undergo a comprehensive cardiovascular evaluation to reveal the extent of atherosclerotic disease. Such an approach affects decision making in the catheterization laboratory and aids in choosing the safest and most effective treatment for the individual patient.