High-risk acute coronary syndrome in a patient with coronary subclavian steal syndrome secondary to critical subclavian artery stenosis.

Patients with multivessel coronary artery disease are more likely to have extensive atherosclerosis that involves other major arteries. Critical subclavian artery (SCA) stenosis can result in coronary subclavian steal syndrome that may present as recurrent ischemia and even myocardial infarction in patients with coronary artery bypass graft (CABG). In patients with concomitant severe native coronary disease, occluded saphenous venous grafts (SVG) to other arteries, percutaneous intervention on critical subclavian artery (SCA) stenosis that will compromise the blood flow to left internal mammary graft (LIMA) and left anterior descending (LAD) artery will be a high-risk procedure and may be associated with cardiogenic shock, especially in patients with preexisting ischemic cardiomyopathy. The use of percutaneous left ventricular (LV) assist device like Impella will offer better hemodynamic support and coronary perfusion and therefore results in decreased myocardial damage, maximized residual cardiac function, and lower incidence of cardiogenic shock.