Although the predominant location of symptomatic carotid artery occlusive disease is the carotid b~cation, proximal common carotid artery lesions cause similar symptoms. Common carotid artery lesions occur as isolated disease or in tandem with carotid bulb disease. Restoration ofcarotid artery inflow from subclavian based extraanatomic bypasses should provide adequate reconstruction of these lesions. To evaluate subclavian-carotid artery bypass, a retrospective revieW' of all patients Wldergoing this procedure from Jan. 1, 1977, to Feb. 20, 1989, was performed. Twenty patients (14 men, 6 women) with a mean age of 60 years were treated. Fifteen patients (75%) were admitted with transient ischemic attacks. Five (25%) had nonfocal symptoms (e.g., dizziness, syncope). Arteriographic evaluation demonstrated severe proximal occlusive disease ofthe common carotid artery in all cases. Reconstruction bypasses were performed to the carotid bulb (45%), internal carotid artery (30%), and external carotid artery (25%). Four patients Wlderwent endarterectomy ofthe internal carotid artery in conjunction with subclavian-carotid artery bypass. Bypass conduits included saphenous vein (75%) and prosthetic grafts (25%).Asymptomatic phrenic nerve neuropraxia was identified by postoperative chest radiography in four cases, with no resultant respiratory disease. No perioperative strokes occurred.. One postoperative death (5%) resulted from a myocardial infarction. Long-term results were available for 18 patients (90%), with 'a mean follow-up of50 months (range, 1 to 122 months). Four patients have died of causes tmrelated to carotid vascular disease. Serial . duplex scans have documented graft patency in all 18 patients. A single patient returned with focal neurologic symptoms as a result of a posterior circulation infarct. This experience documents that subclavian-to-carotid artery bypass appears to be a safe, durable, and well-tolerated procedure for the reconstruction of symptomatic proximal carotid artery stenosis when the subclavian artery is an appropriate inflow source. For this procedure saphenous vein appears to be a suitable conduit. Long-term follow-up demonstrates excellent patency and protection against further anterior circulation neurologic events.
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