A Clinical Decision Making Case on Subclavian Occlusion | Patient Case Quiz

A 67-year-old female with a history of dyslipidemia, hypertension, coronary artery disease status post coronary artery bypass graft (CABG) surgery presents for evaluation of progressive left upper extremity claudication symptoms described as exercise-induced left arm pain, left middle finger tingling, and left arm fatigue. There are no symptoms at rest. CABG includes left internal mammary artery (IMA) to left anterior descending (LAD) artery grafting. Physical exam is notable for a left upper extremity blood pressure of 90/60 mm Hg and right upper extremity blood pressure of 136/66 mm Hg; normal jugular venous pressure, normal S1 and S2 without murmurs; and 2+ right radial pulse, 1+ left radial pulse, 2+ right femoral pulse, 2+ left femoral pulse. Vascular Doppler shows left subclavian artery occlusion (Figure 1) with retrograde flow in the left vertebral artery (Figure 2), and computed tomography scan shows proximal left subclavian artery occlusion with distal left subclavian artery perfusion via retrograde flow from the left vertebral artery (Figure 3). The patient undergoes angiography via the right femoral artery and right radial artery (Figure 4) for further delineation of anatomy and consideration of treatment options.

Figure 1: Vascular Ultrasound Color Doppler Evidence of Subclavian Occlusion Figure 2: Vascular Ultrasound Doppler Evidence of Retrograde Flow in Vertebral Artery

Figure 1

Figure 2

Figure 3: CT Angiogram Evidence of Proximal Subclavian Artery Occlusion Figure 4: Long Segment Proximal Subclavian Occlusion via Invasive Angiography

Figure 3

Figure 4

Which of the following is the next best treatment option in this patient with symptomatic left subclavian steal syndrome?

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