The management of brachiocephalic occlusive disease.

The pathophysiology of transient ischemic attacks (TIAs) is fairly well established. Hemispheric TIAs associated with extracranial carotid lesions have been evaluated extensively. Brain stem insufficiency accounts for between five to 15 per cent of patients with nonneurologic strokes. Basilar artery insufficiency is characterized by "drop attacks," syncope, or bilateral paresthesias. In evaluating some 2,300 patients with cerebral symptoms, we found 361 with brachiocephalic occlusion of such degree that surgery was recommended. We prefer direct anastomosis of the distal subclavian or vertebral artery to its adjacent common carotid artery. We have performed the operation 276 times with a 0% mortality and minimal morbidity. There have been no neurologic deficits as a result of interruption of cerebral flow.