Extrathoracic reconstruction of arterial occlusive disease involving the supraaortic trunks.

PURPOSE

The purpose of this study was to review the various extrathoracic reconstruction options in patients with occlusive disease of the supraaortic trunks and to define the efficacy of these procedures in maintaining graft patency and relieving symptoms.

METHODS

Forty-four consecutive patients underwent 47 extrathoracic bypass procedures of the supraaortic trunks for correction of symptomatic subclavian (SCA), common carotid (CCA) or innominate (INA) artery occlusive disease between July 1975 and May 1994. SCA stenosis (n = 27) was associated with upper extremity claudication (55%), vertebrobasilar insufficiency (15%), or both (30%). CCA stenosis (n = 14) was accompanied by hemispheric symptoms in 86% and global ischemia in 14%, whereas INA stenosis (n = 3) was associated with transient ischemic attacks (67%) and right arm ischemia (33%).

RESULTS

SCA revascularization included carotid-subclavian or carotid-axillary bypass (n = 19), axilloaxillary bypass (n = 8), and subclavian-carotid transposition (n = 3). CCA reconstructions included subclavian-carotid (SC) bypass (n = 13) and carotid-carotid bypass (n = 1). INA procedures included three axilloaxillary bypasses. Six patients had an associated carotid endarterectomy, and three underwent concomitant vertebral artery transpositions. Intraluminal shunts were not routinely used. Vein was used as a conduit in five procedures, and a prosthetic graft (23 Dacron, 16 polytetrafluoroethlyene) was used in the remainder. The average postoperative intensive care unit and hospital and hospital stay were 1 and 5 days, respectively. Follow-up was available in 43 of 44 patients (mean = 26.2 months). The perioperative mortality rate was 2.2% (one axilloaxillary). There were five graft occlusions in procedures involving the axillary artery (3 of 11 axilloaxillary, 2 of 7 carotid-axillary) as compared with one of 29 thromboses when the operation was confined to the supraclavicular fossa (p < 0.05) Relief of symptoms was achieved in all patients with patent grafts. There were no perioperative strokes in the series. Other complications included one brachial plexus neuropraxia (axilloaxillary) and four patients with phrenic nerve neuropraxia.

CONCLUSION

Extrathoracic revascularization of the supraaortic trunks is well tolerated and durable when operations are confined to the supraclavicular fossa and do not involve the axillary artery.