Carotid-subclavian Artery Bypass Research Articles

Hybrid Management of Dysphagia Lusoria with Tevar Implantation and Bilateral Subclavian Arteries Debranching: A Review of the Literature and a Case Report

Aberrant right subclavian artery (ARSA) causing dysphagia, the so-called “dysphagia lusoria”, is a frequent embryologic anomaly of the aortic arch. In symptomatic patients, studies report several management options including surgical, hybrid, and totally endovascular strategies. Hybrid techniques have the advantage of no chest opening with reduced morbidity, but the problem of the ARSA stump causing recurrent or persistent dysphagia remains challenging in some cases. We conducted a literature review on the management strategies of ARSA and presented the case of a 72-year-old female patient with ARSA and dysphagia managed with thoracic endovascular repair of the aorta (TEVAR) and bilateral carotid–subclavian artery bypass. This technique was chosen because of the severe calcifications at the level of ARSA origin that would make surgical ligation difficult, or if an occluder device not suitable. We think that a patient-tailored approach should be considered in cases of dysphagia lusoria, considering that a multitude of strategies are reported.

Carotid-subclavian bypass and endovascular aortic repair of Kommerell’s diverticulum with aberrant left subclavian artery: A case report

BACKGROUND Kommerell’s diverticulum (KD) with aberrant left subclavian artery is a rare congenital deformity and also has very little research literature about it (35% of case study). There are three types of aortic arch diverticulum. Even literature concerning the treatment options are limited. CASE SUMMARY We present a case report of a 50-year-old male with KD in the right aortic arch with aberrant left subclavian artery. We conducted a total endovascular repair procedure, which is innovative and will spread more light in the medical world. Our patient has no past medical history and is a non-smoker and non-alcoholic. Patient presented with shortness of breath, chest pain and dizziness for six months. Blood tests were done and computerized tomography (CT) angiogram of the chest confirmed the diagnosis, illustrating showed a 3.9 cm KD. On Day 1, the CT angiogram showed mild dilatation of the thoracic aorta, adjacent esophagus, trachea was compressed and displaced. Surgery was planned as the treatment modality. Carotid-Subclavian artery bypass and endovascular aortic repair was conducted. We used prolene 5-0 C1 sutures to precisely anastomose a 6-mm Dacron graft to the left subclavian artery. Haemostasis was secured and wounds were closed. Protamine was administered and patient was shifted to intensive care unit. Post-operative, patient responded favorably and was discharged. Regular follow-up is done. CONCLUSION The procedure we performed is novel. This will help the cardio-thoracic surgeons a better insight about the full procedures we conducted, thereby bringing more light and better treatment options in managing KD with aberrant subclavian artery.

Left Subclavian Artery Sacrifice in Acute Aortic Dissection Repair using the Frozen Elephant Trunk.

Surgery of acute aortic dissection using the frozen elephant trunk (FET) can be complicated when the origin of the left subclavian artery (LSA) is dissected and sacrifice by ligation is a viable option. However, the LSA is supposed to play a role in neuroprotection as a major collateral. We, therefore, analyzed our results of LSA sacrifice in this cohort. We identified a total of 84 patients from our prospectively collected database who underwent FET repair of acute aortic dissection between October 2009 and April 2018. LSA was sacrificed in 19 patients (22.6%). Results were analyzed and compared with regard to neurological outcomes. New postoperative stroke was seen in two patients (2.4%) and spinal cord injury in three patients (3.6%) overall, none in the LSA-sacrifice group. We observed a temporary neurological deficit in five patients (6.0%) overall, none in the LSA-sacrifice group. None of the patients developed acute ischemia of the left arm. Only two patients (12.5%) came back for carotid-subclavian artery bypass due to exertion-induced weakness of the left arm 3 to 4 months after the initial surgery. In-hospital mortality was 15.5% overall, with no difference between groups. LSA sacrifice was not associated with elevated postoperative risk of either central or spinal neurological injury. Thus, it can facilitate FET repair of acute aortic dissection in selected cases when the left subclavian origin cannot be preserved. Carotid-subclavian artery bypass became necessary in only a small fraction of these patients and can be performed as a second-stage procedure.

Three Different Strategies for Repair of Symptomatic or Aneurysmatic Aberrant Right Subclavian Arteries.

In this study, we aimed to present three different methods for symptomatic aberrant right subclavian artery (ARSA) surgery. We identified 11 consecutive adult patients undergoing symptomatic and/or aneurysmal ARSA repair between January 2016 and December 2020. Symptoms were dysphagia (n=8) and dyspnea + dysphagia (n=3). Six patients had aneurysm formation of the ARSA (mean diameter of 4.2 cm [range 2.8 - 6.3]). All data were analyzed retrospectively. Median age of the patients (7 females/4 males) was 55 years (range 49 - 62). The first four patients (36.4%) underwent hybrid repair using thoracic endovascular aortic repair (TEVAR) and bilateral carotid-subclavian artery bypass (CScBp). Three patients (27.2%) were treated by open ARSA resection/ligation with left mini posterolateral thoracotomy (LMPLT) and right CScBp. And the last four patients (36.4%) underwent ARSA resection/ligation with LMPLT and ascending aorta-right subclavian artery bypass with upper mini sternotomy (UMS). Two of the four patients who underwent TEVAR + bilateral CScBp had continuing dysphagia cause of persistent esophageal compression. Brachial plexus injury developed in one of three patients who underwent LMPLT + right CScBp. Pleural effusion treated with thoracentesis alone was observed in one of four patients who underwent UMS + LMPLT. Among the symptomatic and/or aneurysmal ARSA treatment approaches, surgical and hybrid methods are used. There is still no consensus on how to manage these patients. In our study, we recommend the UMS + LMPLT method, since the risk of complications with anatomical bypass is less, and we have more successful surgical results.

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.

Hybrid Approach of Ruptured Type B Aortic Dissection with an Aberrant Subclavian Artery in a Single Patient with Turner Syndrome: A Case Report

Turner syndrome, also described as 45, X, may present with most serious cardiovascular anomalies including risk of aortic dissection and rupture. In emergency situation, management for aortic dissection with complicated anatomy accompanying vascular anomaly is challenging. Here, we report a rare case of ruptured type B aortic dissection with aberrant subclavian artery and partial anomalous pulmonary venous connection in a Turner syndrome. Through right carotid-subclavian artery bypass and thoracic endovascular aortic repair, successful hybrid endovascular management correlated with a favorable result in this emergency situation.

In-Situ Laser Fenestration of a PTFE Thoracic Aortic Stent Graft for Delayed Left Subclavian Artery Revascularization Following Frozen Elephant Trunk Repair of Type an Aortic Dissection

Left subclavian artery revascularization during endovascular repair of aortic dissection is often accomplished by left carotid-subclavian artery bypass or transposition. In-situ fenestration of thoracic stent grafts provides an alternative method of revascularization without manipulation of the left carotid artery. We describe a novel technique of delayed in-situ laser fenestration, combined with catheter-directed thrombectomy to revascularize a thrombosed left subclavian artery in a patient with frozen elephant trunk repair of type A aortic dissection.

Long-term results of endovascular repair for descending thoracic aortic aneurysms

ObjectiveSince thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes are lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysms. MethodsOf 579 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 192 (33.2%) were performed for a descending thoracic aneurysm indication in accordance with the device instructions for use, including 106 fusiform (55.2%), 80 saccular (41.7%), and 6 with both saccular and fusiform (3.1%) aneurysms. All aneurysms were located distal to the left subclavian artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day and in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis or paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan-Meier method was used to estimate long-term overall and aorta-specific survivals. ResultsThe mean age was 71.1 ± 10.4 years. All aneurysms in this series were degenerative in nature and no patients with a connective tissue disorder were included. The mean aortic diameter was 5.9 ± 1.5 cm at time of intervention. Rates of 30-day and in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis and paraplegia were 4.7%, 2.1%, 0.5%, and 0.5%, respectively. At a mean follow-up of 69 ± 44 months (range, 3-141 months), there were 68 late deaths (35.4%), two of which were due to aortic rupture. Overall and aorta-specific survivals at 141 months (11.8 years) were 45.7% and 96.2%, respectively. Endovascular reintervention was required in 14 patients (7.3%) owing to type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. No patient required open reintervention for any cause. ConclusionsLong-term (12-year) aorta-specific survival after on-label endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with sustained protection from rupture, and a low rate of reintervention owing to endoleak (7%). Endovascular repair should be considered the treatment of choice for this pathology.

Long-Term Results of Endovascular Repair for Descending Thoracic Aortic Aneurysms

Since thoracic endovascular aortic repair (TEVAR) received US Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes is lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysm. Of 444 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 200 (45.0%) were performed for a descending thoracic aneurysm indication including 113 fusiform (56.5%), 81 saccular (40.5%), and six both saccular and fusiform (3.0%). All aneurysms were located distal to the left common carotid artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day/in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis/paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan- Meier method was used to estimate long-term overall and aorta-specific survival. Mean age was 71.0 ± 10.5 years (Table). All aneurysms were degenerative in nature with no patients with a connective tissue disorder. Mean aortic diameter was 5.8 ± 1.5 cm at time of intervention. Thirty-day rates of in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis/paraplegia were 4.5%, 2.0%, 0.5%, and 1.0%, respectively. At a mean follow-up of 35 ± 32 months (range, 1-156 months), there were 61 late deaths (30.5%), two of which were due to aortic rupture. Actuarial overall and aorta-specific 13-year survival were 43.3% and 95.7%, respectively (Fig). Endovascular reintervention was required in 14 patients (6.9%) because of type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. Zero patients required open reintervention for any cause. Long-term (13-year) aorta-specific survival following endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with a low rate of reintervention due to endoleak (7%), and endovascular repair should be considered the treatment of choice for this pathology.TablePatient and procedural characteristicsDemographicsTotal (N = 200) Age, years71.0 ± 10.5 Male sex55.5% (111) White race72.5% (145) BMI27.9 ± 5.6 ComorbiditiesHypertension91.0% (182)Hyperlipidemia73.5% (147)History of tobacco use68.0% (136)Diabetes mellitus21.0% (42)Coronary artery disease38.0% (76)Congestive heart failure4.0% (8)History of stroke11.0% (22)PAD33.5% (67)COPD33.5% (67)CKD20.5% (41)Connective tissue disorder0.0% (0)Prior aortic surgery40.0% (80)ASA score, median3 (2-4)Case status Elective75.0% (150) Urgent/emergent25.0% (50)Indication for TEVAR DTA, fusiform56.5% (113) DTA, saccular40.5% (81) DTA, fusiform and saccular3.0% (6)Endovascular devices Gore TAG/C-TAG56.0% (112) Medtronic Talent16.0% (32) Cook Zenith10.5% (21) Medtronic Valiant10.0% (20) Cook TX2LP/Alpha Thoracic8.0% (16) Bolton Relay1.5% (3) Medtronic Aneurx0.5% (1)30-day/in-hospital outcomes Mortality4.5% (9) Stroke2.0% (4) New permanent dialysis0.5% (1) Permanent paraparesis/paraplegia0.5% (1)ASA, American Society of Anesthesiologists; BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DTA, descending thoracic aneurysm; TEVAR, thoracic endovascular aortic repair. Open table in a new tab

Hybrid Treatment for Ruptured Diverticulum of Kommerell: A Minimally Invasive Option

Although aberrant right subclavian artery is the commonest aortic arch anomaly, it is a rare entity in clinical practice. While mostly asymptomatic, the rupture of an aneurysm of an aberrant right subclavian artery or Kommerell's diverticulum can be life threatening. A conventional open surgical approach involving sternotomy and resection of the abnormal vessels under circulatory support carries significant morbidity and mortality. We report a case of a ruptured diverticulum of Kommerell that was successfully treated with a hybrid debranching surgery, Amplatzer device embolization of the subclavian vessels, and thoracic aortic endovascular stenting.

Hybrid Repair of Bilateral Subclavian Artery Aneurysms in a Patient with Marfan Syndrome

A 32-year-old man with Marfan syndrome presented with enlarging, asymptomatic bilateral subclavian artery aneurysms. He has an extensive surgical history including aortic arch and descending thoracic aorta replacement. The L aneurysm was treated first with an L carotid-vertebral artery vein bypass, aneurysm debranching, and stent-graft repair of aneurysm via the L brachial artery approach. The R aneurysm was treated by placing a stent graft from the proximal R common carotid artery across the R subclavian artery origin and landing in the prosthetic innominate bypass graft via an L common carotid artery conduit. An aneurysm debranching and R carotid-subclavian artery bypass completed the procedure. A proximal type I endoleak was detected in the R aneurysm sac on follow-up computed tomography angiography. This was treated with sternotomy, aorta to L common carotid artery bypass, stent graft removal, and oversewing of the R subclavian artery origin. The patient recovered uneventfully. Subclavian artery aneurysms are rarely diagnosed in patients with Marfan disease. Although durability remains unproven, hybrid repair should be considered in patients with subclavian artery aneurysms, to minimize the morbidity commonly associated with open repair.

Endovascular Treatment of an Aberrant Right Subclavian Artery Aneurysm with Use of the Zenith Iliac Plug

Aberrant right subclavian artery aneurysms are rare but demonstrate a propensity toward rupture; thus, early elective repair is mandated. Novel endovascular modalities are available to offer less-invasive treatment for a patient population with increasing comorbidities. We report a case of a 65-year-old woman with an aberrant right subclavian artery aneurysm causing dysphagia lusoria. The aneurysm was excluded proximally at Kommerell's diverticulum with a Zenith iliac plug and excluded distally by surgical ligation combined with a right carotid-subclavian artery bypass to preserve extremity perfusion.

Evaluation of a new disease-specific endovascular device for type B aortic dissection

The study objective was to evaluate the feasibility, safety, and early technical and clinical success rate of a new endovascular device specifically designed for aortic dissection that has recently become available in Europe. From June of 2005 to the present, the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark) was used in 11 selected patients (all male, with a median age of 58 years [range, 45-76 years]) with type B chronic aortic dissection with a compression or collapse of the true lumen. All procedures were performed under general anesthesia with preoperative cerebrospinal fluid drainage in 4 patients. One-step open surgical supra-aortic vessels re-routing was performed in 6 patients to obtain an adequate proximal landing zone: Left carotid-subclavian artery bypass was performed in 5 patients, and right-to-left common carotid artery bypass and left subclavian to common carotid artery transposition was performed in 1 patient. Clinical follow-up visits and computed tomography scans were obtained at 1, 6, and 12 months, and yearly thereafter. A secondary technical success was obtained in all patients (100%), and 30-day clinical success was achieved in 10 patients (91%). A type IA entry flow was observed in 1 patient. No mortality was recorded. Occlusion of visceral/renal arteries, retrograde dissections, and device-induced tears in the intimal lamellae were not observed. Periprocedural morbidity included temporary renal failure in 1 patient and postimplantation syndrome with fever and leukocytosis for 23 days in 1 patient. No cases of paraplegia were recorded. At a median follow-up of 12 months (range, 2-30 months), we observed a clinical success rate of 91%. No migration of the device was observed. No late occlusion of the visceral or renal arteries was recorded at follow-up. The perioperative and short-term follow-up results showed that the Zenith Dissection Endovascular System for the treatment of aortic dissection can be safely used without affecting the patency of the branches covered by the bare stent. However, these results need to be validated in a larger group of patients with a mid-term follow-up.

Is it safe to cover the left subclavian artery when placing an endovascular stent in the descending thoracic aorta?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the left subclavian artery may be safely covered with a descending thoracic aortic stent without a prior carotid-subclavian artery bypass or transposition procedure. Altogether 2612 abstracts were identified. Forty-five non-randomized control trials and 213 non-controlled papers were found using the reported search and all these were read in full to search for coverage of the left subclavian artery. From these papers, 20 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 20 studies with more than 10 cases of left subclavian artery coverage without prior revascularisation. Aggregating the data from all these studies we found 498 covered left subclavian arteries. Complications included 13 strokes (2.6%), 8 cases of paraplegia or paraparesis (1.6%) and 6 endoleaks due to subclavian backflow (1.2%). Of note there were 51 cases of ischaemia or other symptoms attributable to poor blood flow (10%), which resulted in 20 post-procedural revascularisations (4%). In three studies the mean pressure drop in the left arm was between 36 and 48 mmHg after left subclavian occlusion. We conclude that coverage of the left subclavian artery has a low, but not insignificant, incidence of side-effects. This incidence must be balanced with the urgency of the procedure and may be acceptable in emergency or salvage situations. However, in non-emergency cases we recommend that the carotid arteries, the vertebral arteries and the Circle of Willis are fully assessed by tests such as duplex ultrasound, angiography, CT or MRI scanning. An absent right vertebral artery, diseased carotid arteries or an incomplete Circle of Willis is a contraindication to left subclavian artery coverage without prior transposition or bypass grafting of the left subclavian artery.

Aortic Debranching for Descending Thoracic Aortic Aneurysm Repair by Stent Grafts

Endovascular repair of a descending thoracic aortic aneurysm may result in covering the ostia of the left carotid or left subclavian artery for proper proximal landing zones, and the celiac artery or superior mesenteric artery ostia in the abdomen for distal landing zones. To prevent possible complications of occluding the ostia of these vessels, the authors performed an innominate to left common carotid and left subclavian artery bypass as the first procedure in one patient. In the second patient they performed an aortoceliac and aortomesenteric bypass before stent graft placement. The stent graft repair of the descending thoracic aortic aneurysm was performed subsequently in both patients. This aortic debranching provides subsequent proper placement of thoracic stent grafts.

Arm ischemia after subclavian flap angioplasty: repair by carotid-subclavian bypass

Though quite unusual, vascular insufficiency of the arm can occur after ligation of the subclavian artery. We describe the ischemic consequences of left subclavian interruption in a neonate after subclavian flap angioplasty repair (Waldhausen procedure) for coarctation. Subsequent carotid-subclavian artery bypass was successful in relieving symptoms.

The Coronary Subclavian Steal Syndrome: An Uncommon Sequel to Internal Mammary-Coronary Artery Bypass Surgery

Coronary subclavian steal syndrome is a possible sequel in patients who have undergone myocardial revascularization with an internal mammary artery. We report a case of this syndrome in a 67-years-old man. In 1990 he underwent a quadruple bypass: aorta-obtuse margin, aorta-right coronary (two sequential), internal artery mammary-descending coronary artery. Three months later he started to have angina pectoris. In April 1992 an aortic arch angiography and a coronary angiography were performed. The examination showed an occlusion of the left subclavian artery at its origin. The artery was opacified countercurrently by the left vertebral artery but the left mammary artery was not opacified. Left coronary angiography showed a very severe disease of left anterior descending coronary artery and retrograde flow through the anastomosis in the left mammary artery. The patient underwent a left common carotid-subclavian artery bypass operation using a 6 mm vascutex graft. Eighteen months later the patient is doing well without angina pectoris and with very little alteration of the perfusion in the left frontal lobe observed by SPECT neuroimaging with a lipophilic tracer (99mTc-HMPAO). We think that the coronary-subclavian steal syndrome can be treated successfully with low risk by means of common carotid-subclavian artery bypass.

Prophylactic Myocardial Revascularization Based on Dipyridamole-Thallium Scanning before Peripheral Vascular Surgery

Cardiac events continue to be the leading cause of perioperative mortality following peripheral vascular reconstruction. The role of preoperative cardiac screening and prophylactic myocardial revascularization in patients without clinical evidence of coronary artery disease is undefined. Fifteen patients with no clinical evidence of coronary artery disease who were found to have reversible defects on dipyridamole-thallium scans and severe correctable coronary artery disease underwent aortocoronary artery bypass grafting. There was one (6.7%) operative death. Three patients (20%) developed postoperative complications: two atrial fibrillation and one breakdown of the saphenous vein harvest site. Thirteen patients underwent subsequent peripheral vascular surgery: seven had abdominal aortic procedures, three infrainguinal reconstruction, two carotid endarterectomy and one carotid-subclavian artery bypass. There were no perioperative or late deaths, cardiac complication, electrocardiographic changes, or episodes of angina associated with the peripheral vascular procedures. Thus, dipyridamole-thallium imaging appears to help select a group of symptom-free, but high cardiac risk, vascular patients in whom preparatory myocardial revascularization and subsequent peripheral vascular surgery can be performed with acceptable mortality and morbidity. The life expectancy of these patients may be improved and, specifically, the risk of their subsequent vascular surgery may be reduced by this approach.

SURGICAL TREATMENT OF SUBCLAVIAN ARTERY OBSTRUCTION

During the past 15 years, 36 patients were hospitalized for arterial obstructive disease of the arm other than that arising from aortitis syndrome. Seventeen arterial reconstructions (two being repeat operations) in 15 patients with subclavian artery obstruction were performed with grafts of the great saphenous vein. Here, we review indications for surgery and surgical methods. When the obstruction was due to arteriosclerosis obliterans, we treated surgically only those patients (n=10) in whom the so-called subclavian steal syndrome caused brain ischemia. Axillo-axillary artery bypass was the operation of first choice because it causes less operative stress than the other usual methods, and because we found that the patency rate of the grafts was good. When as was the case for five patients with brachial plexus injury, revascularization was necessary, and we planned the operative method according to the region of obstruction. That is, when the obstruction was at the origin of subclavian arteries, carotid-subclavian artery bypass was performed. When the obstruction was at the distal part, vein transplantation was carried out. All grafts were patent and results were satisfactory in all five patients.

Extrathoracic repair of branch occlusions of the aortic arch

Thirty extrathoracic operations in twenty-six patients with occlusive disease involving the primary branches of the aortic arch were reviewed. Spanning a fourteen year experience, these operations included carotid-subclavian artery bypass, retrograde common carotid artery thrombectomy, carotid-carotid artery bypass, and femoral-axillary artery bypass. Dacron bypass grafts were used primarily for reconstruction, but saphenous vein bypass and endarterectomy were also employed. Indications for operation, the presence of concomitant cardiovascular disease, surgical technics, patient survival, and late patency of the reconstructions were reviewed. One patient died postoperatively (3.85 per cent). All Dacron grafts were patent on late follow-up examinations. Low mortality and excellent late functional results make extrathoracic repair the approach of choice in the management of occlusive disease of the branches of the aortic arch.