(Stroke. 1995;26:1565-1571.)
© 1995 American Heart Association, Inc.
Articles |
Carotid-Subclavian Bypass for Brachiocephalic Occlusive Disease
Choice of Conduit and Long-term Follow-up
Presented in part at the 19th International Joint Conference on Stroke and Cerebral Circulation, San Diego, Calif, February 17-19, 1994.
From the Section of Vascular Surgery, Department of Surgery, University of California at Los Angeles School of Medicine.
Correspondence to Wesley S. Moore, MD, Section of Vascular Surgery, Department of Surgery, UCLA School of Medicine, 10833 LeConte Ave, Los Angeles, CA 90095.
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Abstract |
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Background and Purpose Atherosclerotic disease of the proximal brachiocephalic circulation may produce disabling symptoms referable to cerebral or upper extremity hypoperfusion and embolization. Bypass of occlusive lesions can provide durable relief of symptoms with minimal complications. The ideal conduit for carotid-to-subclavian and subclavian-to-carotid bypass remains controversial, and it is not clear whether the outflow vessel influences patency and survival.
Methods We performed a retrospective analysis of 60 consecutive carotid-to-subclavian and subclavian-to-carotid bypass procedures. Occlusive lesions were documented preoperatively by arteriography. Patency was determined during follow-up by ultrasound or duplex examination. Actuarial patency, symptom-free survival, and overall survival rates were calculated by the life-table method and analyzed by log-rank test.
Results Arterial transposition demonstrated the highest long-term patency rate (100.0±0.0%). Polytetrafluoroethylene grafts demonstrated the highest bypass graft patency rate (95.2±4.6%), followed by Dacron grafts (83.9±10.5%) and saphenous vein grafts (64.8±16.5%). Symptom-free survival paralleled patency rates, but these differences did not achieve statistical significance. While there were no differences in patency or symptom-free survival by outflow vessel, the overall survival of patients with common carotid lesions was significantly lower than that of patients with subclavian lesions (62.7±12.8% versus 100.0±0.0%; P<.05).
Conclusions The outflow vessel does not affect long-term patency in carotid and subclavian bypass procedures; however, patients with common carotid disease demonstrate significantly poorer long-term survival. Transposition results in superior long-term patency, with a trend toward lower results for synthetic grafts and relatively poor results for autogenous vein grafts.
Key Words: bypass surgery • carotid arteries
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Atherosclerotic disease of the proximal brachiocephalic circulation may produce disabling symptoms referable to cerebral or upper extremity hypoperfusion and embolization. Bypass of occlusive lesions can provide durable relief of symptoms with minimal complications. The ideal conduit for C
SC and
SCC bypass remains controversial, and it is not clear whether the
outflow vessel influences patency and survival. |
Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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From January 1973 to August 1992, 60 extrathoracic C
SC bypass
operations were performed on 53 patients with symptomatic
occlusive disease of one or more branches of the aortic arch. These 60
operations included both CSC bypass for subclavian artery occlusive
disease and SCC bypass for innominate or carotid artery occlusive
disease. The hospital and outpatient records of these patients were
retrospectively reviewed to determine symptoms at
presentation, the location and degree of occlusion as
demonstrated by aortic arch angiography, details of the surgical
procedure performed, immediate postoperative results, relief of
symptoms, long-term patency, and survival. The interval of follow-up
ranged from 0.9 to 168.4 months, with a mean of 44.0 months. The sex distribution of this group of patients was essentially even, with 27 men and 26 women. Patient age at the time of operation ranged from 22 to 77 years, with a mean of 59 years. A history of cigarette smoking was by far the most prevalent risk factor for carotid or subclavian occlusive disease, present in 74% of patients. Other prevalent risk factors included a history of hypertension in 42%, coronary artery disease in 30%, and hypercholesterolemia in 17%. Diabetes was present in only 8% of patients.
Forty-nine of the 53 patients presented with neurological symptoms or symptoms of upper extremity arterial insufficiency, which initiated an evaluation of the cerebrovascular and upper extremity circulation by aortic arch, cerebral, and upper extremity angiography. The etiology of all stenotic, occlusive, and aneurysmal lesions identified by angiography was atherosclerotic disease.
Thirty-two patients were found to have subclavian artery
stenosis, occlusion, or aneurysm and underwent a total
of 37 CSC bypass procedures. The nature of occlusive disease in both
outflow groups is detailed in Table 1
. Eighteen
procedures were performed for isolated subclavian artery
stenosis. Two patients were found to have an associated
internal carotid stenosis (1 ipsilateral, 1 contralateral) that
required concomitant internal carotid
endarterectomy. Thirteen procedures were performed
for patients with complete occlusion of the subclavian artery.
Occlusive disease was much more common in the left subclavian artery,
with 16 stenoses and 11 occlusions, compared with 4
stenoses and 2 occlusions on the right. Additionally, there
were 3 subclavian artery aneurysms and 1
symptomatic proximal anastomotic stenosis of a
previously placed saphenous vein CSC bypass graft.
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Indications for CSC bypass (Table 2) were symptoms of
vertebrobasilar insufficiency (subclavian steal) in 21 patients, upper
extremity claudication and/or weakness in 10, upper extremity
ischemia in 3, subclavian aneurysm in 3, and stroke in
1 (some patients presented with more than one symptom type). Of
the 2 patients with subclavian artery aneurysm, 1 reported
dyspnea and stridor due to airway compression, and 1 reported upper
extremity neurological symptoms presumed secondary to brachial plexus
impingement and had a contralateral asymptomatic
subclavian artery aneurysm.
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Twenty-one patients were found on angiography to have innominate (n=4)
or common carotid (n=17) artery stenosis or occlusion, and they
underwent a total of 23 SCC bypass procedures. The 4 patients with
innominate artery occlusive disease underwent "crossover" bypass
from the left subclavian to the right common carotid artery. There were
8 patients with an isolated stenosis of the innominate (n=2) or
common carotid (n=6) artery; 1 of these patients had an associated
ipsilateral internal carotid stenosis requiring concomitant
endarterectomy, and 1 had an associated ipsilateral
vertebral artery occlusion for which a SCC graft to vertebral artery
branch graft was constructed. Thirteen patients were found to have
complete occlusion of the innominate (n=2) or common carotid (n=11)
artery. Eleven patients had occlusive lesions of the left common
carotid artery, 4 had lesions of the innominate, and 6 had lesions of
the right common carotid artery. There was 1 patient with a
symptomatic anastomotic stenosis of a previously
placed saphenous vein bypass graft and 1 with an infection of a
previously placed prosthetic SCC bypass graft, for a total
of 23 SCC bypasses.
The indications for SCC bypass (Table 2
) were TIAs of the anterior
circulation in 13 patients, stroke in 3 patients, syncope in 1, and
graft infection in 1. Four patients underwent SCC bypass for
asymptomatic high-grade common carotid artery
stenosis with contralateral carotid artery occlusion.
The mean age at operation of patients undergoing CSC bypass was 57
years compared with 61 years for patients undergoing SCC bypass.
Revascularization was accomplished with the use of
the following conduits: PTFE grafts in 25 patients, Dacron grafts in
15, autogenous saphenous vein in 11, and arterial
transposition in 9. The distribution of conduit types by outflow vessel
is detailed in Table 3. Each conduit was used in more
subclavian outflow bypasses than carotid. The type of conduit used in
each case was determined by the personal preference of the attending
surgeon. All operating surgeons were vascular surgery faculty of the
UCLA Department of Surgery.
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Inpatient medical records were reviewed to determine the incidence and nature of complications. Patients were followed up by routine outpatient visits, in most cases every 6 months for the first year and then annually. Outpatient evaluation included historical information regarding recurrence of symptoms, physical examination, and duplex examination of the bypass to determine patency. No bypasses were considered patent unless unequivocally proven by ultrasound or duplex examination. Results were analyzed in terms of long-term patency, relief of symptoms, and survival and were calculated by the Kaplan-Meier life-table method. Results are presented graphically with the calculated standard error for each interval reported in parentheses. Statistical evaluation of life-table data was performed with the use of the log-rank test. Statistical significance was defined as P<.05.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Patency Rates
The 5-year Kaplan-Meier patency rate for all 60 bypasses was 87.5±4.8%. The vessel of outflow had no effect on long-term patency, as the patency rate for SC
C bypass grafts was 88.2±8.0% compared
with 86.7±6.2% for CSC grafts (Fig 1).
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Of the four conduit types, arterial transposition
demonstrated the best long-term results, with a 5-year patency rate of
100.0±0.0%. Only one occlusion of an arterial
transposition was observed during the entire follow-up period,
occurring at 168.4 months (>13 years) postoperatively. This patient
was asymptomatic at the time the occlusion was detected
by duplex examination. PTFE grafts demonstrated the highest patency
rate of three bypass grafts used, with a 5-year patency of 95.2±4.6%,
followed by Dacron grafts at 83.9±10.5% (Fig 2).
Saphenous vein grafts demonstrated 5-year actuarial patency of
64.8±16.5%. The differences between these four groups were not
statistically significant (P=.20).
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Four patients required an interventional procedure or operation during
the follow-up interval to relieve symptoms due to bypass
stenosis. One CSC transposition patient underwent
angioplasty at 4 and 8 months postoperatively for an anastomotic
stenosis and was patent and asymptomatic at
last follow-up (16.9 months). One CSC saphenous vein bypass patient
underwent angioplasty 16 months postoperatively for a proximal
anastomotic stenosis at the time of an ipsilateral internal
carotid endarterectomy and was patent and
asymptomatic at last follow-up (89.9 months). One
SCC PTFE bypass patient underwent operative revision of the distal
anastamosis at 75 months for recurrence of symptoms and was
also patent and asymptomatic at last follow-up (136.3
months). One CSC saphenous vein bypass patient required surgical
graft thrombectomy immediately after operation and was found to be
symptomatic with an occluded graft at 12.9 months of
follow-up. The patency data reflect primary, unassisted patency for all
other bypasses.
Symptom-Free Survival Rates
Symptom-free survival rates closely paralleled patency
rates. The 5-year symptom-free survival rate for all patients was
85.5±5.1%. The outflow vessel had no significant effect on
symptom-free survival rates, as 86.6±6.3% of CSC bypass patients
and 83.2±8.9% of SCC bypass patients reported no return of
symptoms referable to subclavian or innominate/carotid occlusive
disease at last follow-up (Fig 3). Five-year
symptom-free survival rates by type of conduit paralleled the
observed patency rates: 100.0±0.0% for transpositions, 90.5±6.4%
for PTFE grafts, 83.9±10.4% for Dacron grafts, and 63.6±17.7% for
saphenous vein grafts (Fig 4). As for patency rates, the
symptom-free survival rates demonstrated the best results for
arterial transposition, with slightly poorer
performance for synthetic grafts and the worst
performance for vein grafts. These differences, however, did
not reach statistical significance (P=.19).
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One patient with a left carotid occlusion and left hemispheric TIAs who
underwent left SCC bypass reported persistent symptoms at last
follow-up despite a patent bypass graft. This patient was lost to
follow-up at 1.8 months, and an explanation for the persistence of
symptoms was not determined.
Overall Survival Rates
Five-year survival for the 60 patients as a whole was 83.5±6.6%.
The anatomic location of the bypassed occlusive disease markedly
influenced long-term survival (Fig 5). There were no
deaths during the follow-up period among patients with subclavian
stenosis undergoing CSC bypass, for a 5-year survival of
100.0±0.0%. This contrasts with a 5-year survival of 62.7±12.8% for
those patients with innominate or carotid disease undergoing SCC
bypass (P<.05). There were no differences in mortality
between the four conduit types.
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Seven of the 23 SCC bypass patients are known to have died during
the follow-up period. One perioperative death due to
myocardial infarction occurred 3 weeks after surgery. Other
atherosclerosis-related deaths included the following:
1 respiratory death due to complications of a
perioperative stroke at 13 months, 1 fatal myocardial
infarction at 39 months, and 1 death due to heart failure at 79 months.
There were two cancer-related deaths: 1 due to laryngeal cancer at 17
months and 1 due to gastrointestinal cancer at 45 months. There was 1
death at 15 months due to respiratory complications of a
perioperative respiratory arrest.
Operative Complications
Twelve operative complications occurred in 11 patients, for an
overall complication rate of 18.3%. These complications included 2
strokes (stroke rate, 3.3%), 3 thoracic duct injuries, 2 nerve
injuries, 2 hematomas, 1 myocardial infarction, 1 respiratory arrest
with hypoxic brain injury, and 1 graft thrombosis. There was 1 death
due to myocardial infarction within 30 days of surgery, for an
operative mortality rate of 1.7%. Three patients underwent reoperation
during the same admission: 1 for thoracic duct ligation, 1 for
evacuation of a hematoma, and 1 for Fogarty catheter thrombectomy of a
graft thrombosis. This represents an early reoperation rate of
5.0%.
The operative complication rate was greater for SCC bypasses, at
35% (8/23), compared with a rate of 11% (4/37) for CSC bypasses
(P<.05). Both myocardial infarctions and nerve injuries
occurred in the SCC bypass group. The nerve injuries involved
transient unilateral vocal cord paralysis presumed secondary to
traction or crush injury of the recurrent laryngeal nerve. There was 1
stroke and 1 wound hematoma in each outflow group. Two of 3 thoracic
duct injuries occurred in the CSC bypass group. Two of these
injuries were managed nonoperatively by temporary thoracostomy tube
drainage of a chylous pleural effusion and bowel rest with parenteral
nutrition; 1 patient underwent reoperation with thoracic duct
ligation.
The 2 patients who suffered a postoperative stroke underwent urgent
extrathoracic revascularization for crescendo TIAs
and limb-threatening ischemia, respectively. One of these
patients had a known recent left carotid artery occlusion and developed
left-hemispheric TIAs, for which a left SCC bypass was performed.
The other patient was found to have an occluded left subclavian artery
on evaluation for severe left upper extremity ischemia with
distal gangrenous changes and suffered a left middle cerebral artery
distribution stroke after left CSC bypass.
Late Complications
One graft infection was observed in this group of patients during
the follow-up interval, for an infection rate of 1.7%. This occurred
in a Dacron SCC bypass at 17.6 months of follow-up. This
complication required graft removal and revision; however, follow-up
information for this procedure was not available.
Other late complications after SCC bypass included 1 saphenous vein
bypass patient with return of symptoms at 1.8 months despite a patent
graft, 1 PTFE bypass patient with recurrent symptoms at 75 months
requiring graft revision, and 1 Dacron bypass patient who suffered an
ipsilateral stroke 12 months postoperatively. This patient was found to
have a patent graft, with an ulcerated common carotid artery plaque
proximal to the graft–carotid artery anastamosis. Ligation of the
proximal common carotid artery was effective in preventing further
neurological events. The incidence of late stroke was thus 4.3% for
SCC bypass patients.
Late complications among CSC bypass patients included 2 patients
with stroke, for a late stroke incidence of 5.4%, similar to that of
SCC bypass patients. One patient who underwent CSC bypass for
upper extremity ischemia experienced an ipsilateral stroke at
10.9 months and was found to have an occluded graft. The embolic source
for this event could not be determined. The other stroke occurred at
14.0 months in a saphenous vein bypass patient who was found on
angiography to have a critical ipsilateral internal carotid artery
stenosis, as well as stenosis of the proximal graft
anastamosis. This patient underwent internal carotid
endarterectomy and graft angioplasty, with no
further neurological events and documented graft patency at 89.9
months.
Other late complications among CSC bypass patients included 1
saphenous vein graft thrombosis at 12.9 months with return of symptoms
and 2 patients previously described who required angioplasty to
maintain graft patency and relieve recurrent symptoms (1 patient at 4
and 8 months, the other at 16 months).
Choice of Conduit
The first 30 bypasses were performed from 1973 to 1983. The choice
of conduit for these bypasses included 11 Dacron grafts, 10 saphenous
vein grafts, 6 PTFE grafts, and 3 arterial transpositions
(Fig 6). Follow-up data on conduit performance
from the earlier patients in the series1 clearly
influenced subsequent choice of conduit, as the use of vein decreased
in favor of transposition and synthetic grafts, and among synthetic
grafts the use of Dacron decreased in favor of PTFE. Conduits used for
the last 30 bypasses from 1984 to 1992 were as follows: 18 PTFE grafts,
6 arterial transpositions, 4 Dacron grafts, and 1 saphenous
vein graft.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Proximal occlusive disease of the common carotid and subclavian arteries is encountered infrequently among patients with peripheral vascular disease, particularly in comparison with carotid bifurcation disease. In the Joint Study of Extracranial Arterial Occlusion, only 17% of 6534 patients were found to have a stenosis of 30% or greater in either the innominate or subclavian arteries.2 Accumulated experience with such patients suggests that in most cases these lesions remain asymptomatic and progress slowly.3 4 5 6 It is therefore difficult to make a convincing argument for prophylactic surgical intervention in asymptomatic patients with proximal subclavian or carotid artery disease.
Because of the very low risk of suffering an infarct, most surgeons agree that surgery is only indicated for those patients experiencing frequent and disabling symptoms.7 8 Extrathoracic revascularization by arterial transposition or bypass has emerged as the treatment of choice for symptomatic patients with proximal subclavian and carotid occlusive disease as a result of the high morbidity and mortality rates associated with transthoracic approaches.9 10 11 Patients with subclavian stenosis or occlusion require surgical intervention for symptoms of vertebrobasilar insufficiency due to subclavian steal or for symptoms of upper extremity ischemia such as claudication or distal embolization. Those with stenosis or occlusion of the common carotid artery most frequently require revascularization for TIAs, stroke, or syncopal episodes. While experience suggests that stroke is a relatively uncommon sequela in this patient population, particularly in those with subclavian disease, the functional disability is significant. Modern series that use the extrathoracic approach in symptomatic patients have demonstrated durable relief of symptoms, with mortality rates of 0% to 3% and perioperative stroke rates of 0% to 5%. The operative mortality rate of 1.7% and perioperative stroke rate of 3.3% observed in this report are consistent with past experience.
A consensus has not been reached regarding the appropriate management of a hemodynamically significant but asymptomatic proximal common carotid artery lesion. As a result, clinical practice in this setting has varied. This series includes four patients who underwent revascularization for asymptomatic high-grade proximal carotid artery stenoses. It should be noted, however, that each of these patients also had a contralateral carotid artery occlusion and was therefore at risk for a catastrophic neurological event upon occlusion of the patent carotid artery.
The selection of the ideal conduit for CSC reconstruction has been
controversial, and accumulating evidence suggests that the choice of
conduit does have a significant effect on long-term patency. In this
series arterial transposition demonstrated superior
results, with 100% 5-year actuarial patency. Only one occlusion of an
arterial transposition was observed during the entire
follow-up interval, at more than 13 years after surgery. Our experience
with transposition parallels that of other modern series, which have
reported early (30-day) patency rates of 100% and long-term patency of
95% to 100%, with somewhat lower results for vein grafts or
prosthetic bypass grafts.1 12 13 Because of these
excellent results, some vascular surgeons have adopted
arterial transposition as the
revascularization procedure of choice. Weimann et
al14 reported a series of 38 patients with
symptomatic subclavian steal, all of whom underwent
CSC transposition, with 97% patency during an average follow-up
interval of 13 months. Edwards et al15 recently reported
the largest series of CSC transposition, in which 178 patients
followed up for a mean interval of almost 4 years had a patency rate of
99%.
A number of factors may be responsible for the superior performance of arterial transposition compared with prosthetic and venous bypass grafts. By virtue of the fact that only a single anastomosis is constructed, the theoretical risk of anastomotic complications is in essence reduced by half. Additionally, since a nonarterial conduit is not interposed between the carotid and subclavian arteries, the subsequent development of intimal hyperplasia related to compliance mismatch may be averted. Transposition also provides an advantage over prosthetic materials with respect to thrombogenicity and an advantage over autologous vein with respect to size match. Initial concerns regarding the possibility of ipsilateral hemispheric ischemic episodes from either the creation of a "carotid steal" or as a result of intraoperative common carotid artery cross-clamping have proven to be unfounded. We and others have observed that a carotid steal will only occur in the presence of a proximal common carotid occlusive lesion, and modern series have failed to report a single perioperative stroke attributable to the operative clamping of the common carotid artery during a transposition procedure.
Of the conduits used for CSC bypass, PTFE demonstrated the best
results with a 5-year actuarial patency of 95.2±4.6%, followed by
Dacron grafts at 83.9±10.5%. Saphenous vein grafts had the poorest
long-term patency rate, at 64.8±16.5%. While there was a trend toward
poorer patency for saphenous vein grafts and PTFE grafts appeared to
perform better than Dacron grafts, the differences between these four
groups was not statistically significant (P=.20). As the
overall 5-year patency rate is relatively high for all 60
bypasses/transpositions (87.5±4.8%), a greater number of patients
would be required to demonstrate a statistically significant difference
between each type of conduit. Saphenous vein grafts also more
frequently required subsequent intervention, such as thrombectomy or
angioplasty, to maintain graft patency.
A difference in performance between prosthetic grafts
and autogenous vein grafts was first noted by the senior author in
1986.1 In this review of 31 bypass procedures, we reported
a 5-year patency rate by life-table methods of 91% for
prosthetic grafts (n=18) compared with only 57% for saphenous
vein grafts (n=13). Our experience with prosthetic and
saphenous vein bypass grafts parallels that reported in the literature
during the past 30 years. In the cumulative published experience from
1962 to 1994, when we examine those series in which results were
analyzed according to the choice of conduit, the patency rate
for 389 prosthetic grafts is 97% compared with 83% for vein
grafts (length of follow-up varied between
series).1 8 11 12 16 17 18 19 Several factors may explain the
superior performance of prosthetic conduits in CSC
bypass procedures. These include the relatively small size of
autogenous saphenous vein grafts in comparison to prosthetic
grafts and the potential for graft kinking due to neck motion in
several axes. The inherent stiffness of prosthetic grafts may
provide some advantage for grafts in this position. Some surgeons have
used prosthetic grafts exclusively to avoid the potential
patency problems associated with vein grafts.20 The
theoretical advantage of a decreased risk of graft infection with vein
grafts does not appear to be an important factor, since only one graft
infection occurred in this series of 60 bypasses (1.7%). It is
notable, however, that in one recent series including 15 CSC bypass
grafts constructed with autogenous saphenous vein, the long-term
patency rate during a follow-up interval of 1 to 122 months was
100%.19 All of these grafts were SCC bypasses
performed for proximal common carotid lesions, and it is possible that
this graft configuration, as well as the relative low resistance of the
cerebral circulation compared with that of the upper extremity,
contributes to the favorable outcome observed.
Experience with these bypass materials early in the series clearly
influenced the choice of conduit in later patients (see Fig 6). During
1973 to 1983, Dacron and saphenous vein were most commonly used, with
only six PTFE grafts and three transpositions performed. Because of the
number of occlusions observed with vein grafts and the excellent
results with PTFE grafts and transposition, during the second half of
this series the use of saphenous vein was essentially abandoned. PTFE
was used most frequently, and the number of arterial
transpositions performed doubled.
It is notable that of the seven grafts that were observed to fail during the follow-up interval (a mean of 44.0 months), all failures occurred within the first 17 months. This observation suggests that technical and anatomic factors related to bypass graft construction significantly influenced later patency. Those grafts with adequate caliber, inflow, and outflow were thus likely to remain patent indefinitely, while grafts that were suboptimal with respect to any of these factors failed within a relatively short amount of time.
Revascularization provided relief of symptoms due to subclavian or carotid occlusive disease in all patients with patent bypasses. Five-year actuarial symptom-free survival rates paralleled patency rates when examined by both outflow vessel and type of conduit. There was no significant difference in symptom-free survival rates between bypasses with carotid outflow versus those with subclavian outflow. Transpositions demonstrated a 100% 5-year symptom-free rate, followed by PTFE at 90.5%, Dacron at 83.9%, and saphenous vein at 63.6%. Again, these differences fell short of statistical significance as a result of the small number of failed bypasses (P=.19).
While the anatomic location of the bypassed occlusive lesion had no effect on either graft patency or the overall symptom-free survival rate, location markedly influenced the overall survival rate. The actuarial 5-year survival of patients undergoing revascularization for proximal subclavian disease was 100%, compared with 62.7% for patients whose indication for operation was an innominate or common carotid lesion. This difference was statistically significant (P=.001). The reasons behind this observation are not clear. Since these widely divergent survival statistics occurred in the absence of any significant difference between the two groups in patency or relief of symptoms, graft durability or function cannot be implicated. One possible explanation may be that the natural history of atherosclerosis in patients with disease affecting the carotid circulation is more rapidly progressive than that of patients with occlusive lesions of the subclavian artery. Patients with carotid occlusive disease may be more likely to have associated coronary artery disease. The one perioperative death and two of the six late deaths in this group were attributable to myocardial ischemia.
In summary, our experience with CSC bypass suggests that
arterial transposition is the conduit of choice for
revascularization of symptomatic
brachiocephalic occlusive disease. Prosthetic grafts
demonstrated slightly lower patency results, and the
performance of vein grafts was relatively poor. Although these
differences fell short of statistical significance because of the high
overall patency rate, they concur with trends observed by other
authors. Long-term patency was not influenced by whether the occlusive
disease is in the subclavian versus common carotid/innominate location;
however, patients with common carotid/innominate disease had
significantly lower long-term survival. This finding may be due in part
to more advanced systemic atherosclerotic disease. CSC bypass can
provide durable relief of disabling symptoms with minimal mortality and
acceptable morbidity.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was supported in part by a grant from the Joash Foundation.
Received January 27, 1995; revision received May 8, 1995; accepted June 8, 1995.
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References |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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