Due to an incidence of SA stenoses of up to 2.7% in patients requiring CABG surgery and the increased use of the IMA as a CABG-conduit, a standardized preoperative screening of these patients for SA stenoses before undergoing CABG surgery using the IMA has been repeatedly recommended [
1,
11,
12]. In the case of a SA stenosis, a simultaneous therapy performing the CABG and an interventional or surgical therapy for the SA lesion should be considered [
10]. The clinical presentations vary from an asymptomatic steal phenomenon to silent ischemia [
1,
10,
12,
14], unspecific cardiac symptoms [
4], rarely different forms of MIN [
8] or even heart failure [
10]. Our patient suffered from a manifest NSTEMI with elevated troponin levels and clinical symptoms. The SA stenosis may also lead to symptoms in the arm after exhaustive strain, including all symptoms of extremity ischemia [
1,
12], which were also present in our patient. Diagnostic procedures include bilateral blood pressure measurements (in case of physiological measurements also with careful provocative studies), as well as Doppler and duplex sonography of the SA [
1,
8,
15]. To evaluate the vascular configuration as well as the presence of a stenosis or occlusion and to validate the patency of the arteries, a CT- or MR-A of the aortic arch and its branches might be performed [
1,
8]. Angiography remains the gold standard as it may be performed together with an additional CA. It can prove the patency of the CABG and allows a simultaneous therapeutic intervention of the SA pathology [
8]. Regarding the therapeutic options, interventional procedures like plain old balloon angioplasty (POBA), stent implantation [
15,
16], cutting balloon or laser [
1] as well as various open surgical approaches like the performance of a CSB [
1,
12], an aorto-subclavian bypass [
1], a carotid-axillary bypass [
10], an axillo-axillary bypass [
1], a subclavian-to-carotid transposition [
17], a subclavian-subclavian bypass [
17,
18] or a re-insertion of the IMA-graft into the aorta [
1] have been described. In case interventional therapy is not an option or a failed interventional therapy attempt, mainly due to severe calcifications of the SA, bypass surgery is required [
1,
19]. That is even the case in sick patients with severe CSSS symptoms, where an interventional therapy was attempted initially [
4]. Even if most CSSS might be treated interventionally, a few reports, including our case, suggest that bypass surgery is possible even in advanced stages of CSSS as demonstrated in our patient, who suffered a NSTEMI [
4,
10]. Regarding our approach, it is
crucial to rule out an ICA stenosis before performing a CSB to prevent cerebral ischemia [
12]. Regarding the surgical treatment of the CSSS in general, excellent long term results might be achieved while 5-year re-stenosis rates of POBA and stent therapies reach 41% and 16%, respectively [
10].