Long Term – Twenty Nine Years – Results of the Conventional Surgical Treatment of the Subclavian Steal Syndrome – A Single Center Experience

Abstract

Introduction: The aim of the study was to assess the patency rates, symptoms resolution rates and the safety of the surgical procedures performed in the conventional surgical treatment of the subclavian steal syndrome, which is caused by severe atherosclerotic lesions of the proximal part of the subclavian or innominate artery and may result in cerebral or upper extremity ischemia. Vast majority of those lesions may be treated with endovascular methods. However, in particular cases conventional surgical procedure remains the best option. Methods: A retrospective review of 75 patients with subclavian steal syndrome, who underwent conventional surgical treatment in our Department between 1988 and 2019, was performed. The vertebrobasilar insufficiency symptoms that covered: dizziness, vertigo, headache, tinnitus, drop attacks, perioral numbness, visual disturbances and arm claudication were most commonly presented among our study group. The indications for surgical treatment included: 44 subclavian artery occlusions, 18 failed angioplasty procedures, 7 innominate artery stenosis, 3 innominate artery occlusions, one carotid subclavian graft thrombosis and 2 restenoses after multiple transluminal angioplasties with stent implantation. The following vascular procedures were performed: 38 subclavian-carotid transpositions, 16 carotid-subclavian PTFE bypasses, 16 endarterectomies of the subclavian or innominate artery, 4 aorto-subclavian or aorto-innominate artery bypasses and one carotid-subclavian side-to-side anastomosis. During long-term follow-up period each patient underwent clinical examination, blood pressure ratio measurement between upper extremities, ultrasound examination and spiral Computed Tomography angiography at regular intervals. The life table method was used to calculate patency rate, overall survival rate, and symptom-free survival. Results: 30 day primary patency and symptom-free survival were observed in 69 patients (92%). Early thrombosis of subclavian artery with concomitant stroke complicated 3 operations (4%), temporary left phrenic nerve disfunction was observed in 5 cases (6,7%) and lymph leak occurred in 6 patients (8%). In one patient with Marfan syndrome a post-operative dissection of the transposed subclavian artery with the vessel obstruction was observed - despite this partial resolution of symptoms was achieved (1,3%). One patient died due to stroke after transposition complication treatment (1,3%). 49 out of the 75 patients (65,3%) of study group remained under direct supervision during the follow-up period ranging from 1 to over 19 years (12-228 months). 7 stenoses of the subclavian artery (14,3%), one subclavian artery occlusion (2%), one false aneurysm of innominate artery (2%), 6 vertebral artery occlusions (12,2%) and one subclavian dissection were stated (2%). Despite those findings 41 patients (83,6%) remained asymptomatic during the whole follow-up period. Conclusion: 1. Surgical treatment of the subclavian steal syndrome is featured with low mortality rate and relatively small number of complications. 2. Long term patency rate exceeding 80 % combined with good symptom-free survival confirms the efficacy of conventional surgical treatment. 3. Open surgery should be the treatment of choice in case of severe in-stent restenosis or occlusion after endovascular procedures. Disclosure: Nothing to disclose