We prospectively evaluated 59 patients who were deemed candidates for coronary bypass surgery after coronary artery angiography for subclavian artery narrowing, which could compromise the ipsilateral internal thoracic artery graft. Bilateral arm blood pressure (BP) measurements, auscultation for supraclavicular or cervical bruits, and questioning about cerebrovascular ischemic symptoms were compared to brachiocephalic-subclavian arteriography. One neurologic complication occurred during arteriography. An upper extremity BP difference of > or = 15 mm Hg identified all patients with > or = 50% subclavian artery narrowing. We recommend brachiocephalic-subclavian arteriography only in patients with abnormal noninvasive screening for subclavian stenosis, not routinely.

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We report on a case of multivessel coronary artery spasm preceded by vagal signs and symptoms, which resolved after administration of atropine. This supports that the spasm was triggered by endogenous acetylcholine. Cathet (Fig. 1). Following two sublingual nitroglycerin tablets, his chest discomfort and the injury current resolved. Cardiac enzymes confirmed myocardial necrosis. He subsequently had postmyocardial infarction angina episodes, and he was referred for cardiac catheterization. He was treated with intravenous nitroglycerin and aspirin 325 mg daily.Upon arrival in the cardiac catheterization laboratory, he was asymptomatic and had normal blood pressure and regular sinus rhythm. Intravenous nitroglycerin was infusing at 50 mcg per min. A 6 French JL4 catheter was employed for the left coronary artery. Following the first contrast injection using diatrizoate, the patient developed marked nausea with emesis. He began to develop sinus bradycardia with a heart rate of between 40-45 beats per minute, and his blood pressure began to fall. After 1-2 min, he reported chest discomfort and developed significant ST segment elevation in monitor lead II. For the bradycardia and hypotension, intravenous nitroglycerin was discontinued, his lower exremities were elevated to an allowable level, normal saline was infused at a ''wide open'' rate, and 1 mg of intravenous atropine was administered. The systolic blood pressure reached a nadir of 60 mm Hg and then began to increase. The contrast was switched to ioxaglate. Coronary angiography revealed marked spasm of the proximal left anterior descending coronary artery, proximal principal diagonal artery, proximal principal obtuse marginal artery (Fig. 2a), and two sites in the right coronary artery (Fig. 2b). While other therapies were being readied, his chest discomfort subsided, the monitor lead ST segment elevations resolved, and his blood pressure returned to normal. Intravenous nitroglycerin was resumed, and the normal saline infusion rate was decreased to 125 ml/h. Repeat coronary angiography showed resolution of spasm at all five coronary artery sites (Fig. 3a,b). The left anterior descending and circumflex coronary arteries had mild atheroslerotic disease and the third portion of the right coronary artery had a 90% stenosis (Fig. 3b), which was successfully treated by balloon angioplasty (Fig. 4).Following percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery, he remained clinically stable. He was discharged on felodipine and isosorbide dinitrate, along with pravastatin and aspirin.