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Direct subclavian—carotid anastomosis for the subclavian steal syndrome
EurJ Vasc Surg 1,305-310 (1987)
Direct Subclavian-Carotid Anastomosis for the Subclavian Steal
Syndrome S e p p W e i m a n n 1, H a n s W i l l e i t 2 a n d G e r h a r d Flora 1 1 From the Departments of Vascular Surgery and 2 Neurology, Innsbruck University, Anichstrasse 35, A 6 0 2 0 Innsbruck, Austria Between 1984 and 1986, 38 patients--25 males and 13 females--underwent treatment for proximal subclavian arteriosclerotic lesions. All of these patients presented with syrr~ptoms of the subclavian steal syndrome and 13 (34.2%) had additional claudication of the arm. Preoperative angiography showed distal filling of the subclavian artery via retrograde flow in the vertebral artery. 31 patients (81.5%) had total occlusion of the proximal subclavian artery and 7 (18.5%) presented with severe stenosis. 34 of these lesions were on the left (89.5%) and 4 on the right side (10.5%). Complete cerebral angiography was performed in each patient with emphasis on visualisation of the carotid bifurcation and selective opacification of the aortic arch vessels if indicated. Doppler ultrasound flow measurement in the vertebral artery yielded the basic data which were then used for comparative postoperative evaluation. The operation was performed under general anaesthesia and heparinisation. A shunt was not required while performing the direct end-to-side anastomosis between the transected subclavian and the common carotid artery, Arteriosclerotic plaques in the distal stump of the transected subclavian artery and occasionally the origin of the vertebral artery were dealt with by simple eversion endarterectomy. There was no operative mortality; the postoperative complication rate was 13.1% including palsy of the recurrent nerve in 3 patients, a lymphatic cyst of the neck in one patient and bleeding requiring re-exploration in another. Occlusion of the reconstructed artery or neurologic deficit did not occur. Post operatively all patients were treated with platelet inhibitors. The average follow-up period was 13 months, when the reconstructed arteries were found to be patent in 37 patients (97.4%). In all patients, relief of the previously existing symptoms of the subclavian steal syndrome and arm claudication occurred. The 1-year results of this procedure are very satisfactory and in our department subclavian carotid transposition has therefore become the method of choice in the surgical treatment of the subclavian steal syndrome. Key Words: Subclavian artery; Common carotid artery; Subclavian steal syndrome; Subclavian artery occlusion; Subclavian carotid transposition; Arm claudication.
Introduction
A great variety of operative techniques have been described to m a n a g e obstructive lesions of the proximal subclavian artery. Most of these techniques have however some disadvantages: transthoracic subclavian endarterectomy and aorto-subclavian bypass surgery require a thoracotomy which m a y entail significant mortality and complication rates t,2 and carotid subclavian bypass grafting 3,4 requires two anastomoses which rePlease address reprint requests to: Sepp Weimarm, Department of Vascular Surgery, Innsbruck University, Anichstrasse 35, A 6020 Innsbruck, Austria. 0950-821X/87/050305 + 06 $03.00/0
© 1987 Grune & Stratton Ltd
quires clamping of the carotid artery. Another disadvantage of this procedure is that residual occlusive disease must often be left in the proximal subclavian artery and at the origin of the vertebral artery, thus limiting the potential improvement in cerebral perfusion. Other extra anatomic techniques, such as axillary-axillary bypass, do not require clamping of the carotid artery but have yielded unsatisfactory long-term patency and should therefore be reserved for high-risk patients with advanced systemic disease. The procedure of choice should be an extrathoracic approach, in which prosthetic grafts can be avoided, carotid occlusion minimised, and perfusion of the brain and upper extremities improved by re-establishing ante-
306
S. Weimann e t al.
Fig. 1. Duplexpulsed Dopplerultrasound tomography (7.5 MHZB-Scan, 3 MHZDoppler)of the left vertebral artery in a 63-year-oldmale patient presenting with total occlusion of the left proximal subclavian artery. Sagittal 13-mode display identifies the left ventebral artery, reversal of the waveformin Dopplerfrequencyanalysis indicates subclavian-steal-syndrome.
grade flow into the vertebral artery via a single end-toside anastomosis. Therefore direct anastomosis between the distal end of the divided proximal subclavian artery and the common carotid artery is now widely used in the treatment of patients with proximal subclavian occlusion. s, 6,7 We report here our experience with this method over the past 2 years.
M a t e r i a l s and M e t h o d s
Thirty-eight patients, 25 males and 13 females aged thirty-five to seventy-nine, were treated at the Department of Vascular Surgery, Innsbruck University, Austria. All of them presented with symptoms of the subclavian steal syndrome and 13 had additional exercise-related symptoms in the upper extremities. The left side was involved in 34 patients and the right side in four patients. Each patient was subjected to a thorough physical examination, including Duplex pulsed Doppler ultrasound tomography and Doppler frequency analysis to evaluate the direction of flow in the vertebral artery. Pre-operative Duplex examination showed reversed flow in the vertebral artery in all cases (Fig. 1). Furthermore arteriography was performed in 27 patients showing complete occlusion of the left subclavian artery (Fig. 2) which was bilateral in tbur patients. Seven patients presenting with sclerotic stenosis of the left subclavian artery also had obstruction of the opposite side. Two patients were of Eur ] Vasc Surg Vol 1, October 1987
great interest since there was an additional severe contralateral stenosis of the carotid bifurcation and they first had to undergo reconstruction of the carotid bifurcation.
Operative technique A supraclavicular transverse incision is made 1 cm above and parallel to the clavicle. The clavicular head and sometimes the entire sternocleidomastoid muscle is transected. We do not divide the anterior scalene muscle. Dissection of the proximal part of the subclavian artery is performed to facilitate exposure of the internal m a m m a r y artery which is sometimes ligated, Finally the origin of the vertebral artery is identified. Upon completion of the dissection, the origin of the subclavian artery from the aortic arch can be visualised so that a small clamp can be applied. Subsequently the common carotid artery is exposed over a length of approx 4 cm, carefully preserving the vagus nerve and the lymphatics entering the internal jugular vein; the proximal portions of the subclavian and common carotid arteries are frequently very close together. At this point in time the patient is fully heparinised; and the subclavian artery transected close to the aortic arch and the proximal stump is oversewn or ligated with 3/0 monofflament sutures. In some patients presenting with dense arteriosclerotic plaques in the peripheral stump of the subclavian artery extending into the orifice of the vertebral artery, endarterectomy
Direct Subclavian-Carotid Anastomosis
307
Fig. 2. Preoperative angiogram in a 42-year-old femalepatient showing total occlusion of the proximal left subclavian artery and filling of the left peripheral subclavian artery by retrograde left vertebral artery flow.
m a y be needed. Subsequently great care is taken to choose an area for the anastomosis between the end of the transected subclavian artery and the side of the common carotid artery so that kinking or angulation can be avoided. The carotid artery is then incised longitudinally on its lateral aspect and the anastomosis is performed using 6/0 monofllament running sutures (Fig. 3). No internal shunt is required; the average time of carotid clamping in our patients was 14 min. Before removal of the occluding clamps, vessels are flushed in order to remove air and clots. Then blood flow is first diverted into the a r m and then into the cerebral vessels. The wound is closed in layers and drains inserted.
Results
All 38 patients made a satisfactory recovery and had complete remission of symptoms. The early complications included a lymphatic cyst of the neck in one patient, paresis of the recurrent nerve in three patients and bleeding in one patient. Oscillography and Doppler ultrasound flow measurements in the vertebral artery were performed at follow up demonstrating an antegrade flow in the ver= tebral artery in all patients (Fig. 4). Postoperative angiography was performed in six patients and showed a satisfactory result in all of them (Fig. 5). Postoperatively all patients were given antiplate= EurJ Vasc Surg Vol 1. October 1987
308
S. W e i m a n n e t al.
Fig. 3. Intraoperative view: the transected left subclavian artery is anastomosed to the side of the left common carotid artery. Same patient as shown in Fig. 2.
]Fig. 4. Duplex ultrasound display of the left vertebral artery following subclavian-carotid transposition. Antegrade flow is indicated by an upward amplitude in systolic and diastolic phase. Same patient as shown in Fig. 1. Eur ] Vasc Surg Vol 1, October 19 8 7
Direct Subclavian-Carotid Anastomosis
Fig. 5. Postoperative arch angiogram of the patient shown in Fig. 1, taken 6 days after left subclavian-carotidtransposition. Antegradeflow is present in the left vertebral artery.
let drugs. The average follow-up period was 13 months, during this time the reconstructed arteries were found to be patent in 37 patients. There was no operative mortality.
Discussion Occlusive disease of the proximal subclavian artery may cause severe ischaemia of the upper extremities or the subclavian steal syndrome. The Joint study documented left subclavian stenosis in 8.3% and occlusions in 0.8% 8 of cases. Since m a n y patients are asymptomatic, operative intervention is not necessary in all patients in w h o m arteriography reveals a lesion of the subclavian artery. Selection for operation is therefore based on clinical features rather than on angiographic findings. When treatment is required, total occlusion of the subclavian artery requires surgery, whereas a stenosis can be suc-
309
cessfufly dilated by percutaneous transluminal angioplasty2 Contorni TM and Reivich 11 were the first to report on the reversal of the blood flow through the vertebral artery and its effects on the cerebral circulation. At that time the term "subclavian steal" was coined and the surgical management of this syndrome has led to the development of a number of operative techniques. A transthoracic approach with endarterectomy or bypass techniques yield very satisfactory clinical results but early reports quoted a mortality rate of 9 to 20%. 1,12 Although the mortality after transthoracic repair of occlusive lesions of the left subclavian artery is now much less because of increasing experience, improved anaesthesia and better patient selection, 2,t3-16 the early mortality mentioned above led to the use of extraanatomic bypass procedures,3,17 such as carotid subclavian bypass, TM subclavian-subclavian bypass, 19 axillo-axillary bypass 2° and direct subclavian carotid anastomosis, s Of these procedures carotid subclavian and carotid axillary bypass using saphenous vein or Dacron grafts have enjoyed the greatest popularity. 3,4 In comparison to other procedures direct subclavian-carotid anastomosis, as first reported by Parrot 21 and Edwards 22 has several advantages. No graft is necessary and a single anastomosis is all that is needed. The anastomosis produces antegrade flow which is haemodynamically more satisfactory. Prior to operation it is however important to investigate the carotid circulation by means of angiography. Obstructive lesions of the common carotid artery proximal to the proposed site of anastomosis would cause a reduced inflow and distal lesions would result in a "carotid steal" phenomenon. Blood flow measured at operation was reduced by 20% in the peripheral common carotid artery in our patients but no evidence of carotid steal was detected. 7 Surgically induced carotid steal has however been observed but only following carotid subclavian bypass surgery3 T M If a carotid lesion is detected on preoperative investigation it must be repaired either before dealing with the subclavian occlusion--as was necessary in two of our cases--or simultaneously. In our opinion there is no need for cerebral protection with a shunt during the procedure, and none were used in this series. There were no neurological complications. In contrast Mehigan 6 used an intraluminal shunt when the stump pressure was found to be less than 50 mmHg. Early occlusion of the reconstructed arteries has not been seen in this series. Complete relief of preoperative symptoms of vertebrobasilar insufficiency and claudication of the arm was achieved in all cases. Doppler ultrasound flow measurements in the vertebral artery, arm osciUography and in some cases angiography were per= formed at follow-up to confirm restoration of normal flow Eur] VascSurg Vol 1, October 1987
310
S. W e i m a n n e t al.
in the vertebral artery after surgery. Duplex scanning is of great value both in the diagnosis and follow-up of these patients. It is possible to identify the diameter of the vertebral artery and frequency analysis of the waveform in patients presenting with Subclavian Steal Syndrome shows the typical changes of decreased peak, widening of systolic amplitude and missing diastolic backflow. The importance of antiplatelet agents in these patients remains unresolved. Suffice to say that we used them in all our cases with a 2 year patency of 9 7%.
10
11
12
]3
14
References 1 CRAWVORDES, DE BAKEYME, MORRIS GC, HOWELLJF. Surgical treatm e n t of occlusion of the innominate, c o m m o n carotid, and subclavian arteries: a 10 year experience. Surgery 1969; 6 5 : 1 7 - 3 1 . 2 GRtra JD. Extra- u n d transthorakales Vorgehen beim Subclavian Steal Syndrom. Langenbecks Arch Chir 1975; 339: 704. 3 MOOREWS, MALONE]S, GOLDSTONEJ. Extrathoracic repair of branch occlusions of the aortic arch. Am ] Surg 1976; 132 : 2 4 9 - 2 5 3 . 4 PIERANDOZZIJS, INGALAA, COWEEN8W. Proximal subclavian artery occlusion. Arch Surg 1975 ; 1 1 0 : 1 2 6 - 1 3 0 . 5 DIETHRICH EB, KOOPOT R. Simplified operative procedure for proximal subclavian arterial lesions: direct subclavian-carotid anastomosis. Am ] Surg 1981 ; 142 : 4 1 6 4 2 1 . 6 MEHIGANJT, BUCH WS, PIPKIN RD, FOGARTYTJ. Subclavian-carotid transposition for the sublcavian steal syndrome. Am ] Surg 1978; 136:15-20. 7 SANDMANNW, KREMERK, LERUT], HENNERICI M, AULICHA. Subclavia-carotis-transposition zur Behandiung der Subclavia-verschlul~erkrankung mit Anzapfsyndrom. Chirurg 1980; 51 : 2 2 8 - 2 3 4 . 8 FIELDSWS, LEMAKNA. Joint study of extracranial arterial occlusion. VII subclavian s t e a l - - a review of 168 cases, lAMA 1 9 7 2 ; 2 2 2 : 1139-1143. 9 MOTARJEME A, KEIFER JW, ZUSKA AJ, NABAWI, P. Percutaneous
EurJ Vase Surg Vol 1, October 1987
15 16 17 18 19 20
21 22 23
24
transluminal angioplasty for treatment of subclavian steal. Radiology 1 9 8 5 ; 1 5 5 : 6 1 1 - 6 1 3 . CONTORNIL. Il circolo collaterale vertebro-vertebrale nella obliterazione dell'arteria succlavia alia sua origine. Minerva Chir 1 9 6 0 ; 1 5 : 268-271. REIVICHM, HOLLINGHE, ROBERTSB, TOOLEJF. Reversal of blood flow t h r o u g h the vertebral artery and its effect on cerebral circulation. N Engl J Med 1 9 6 1 ; 2 6 5 : 8 7 8 - 8 8 5 . EHRENFELDWK, CHAPMANRD, WYLIE EJ. M a n a g e m e n t of occlusive lesions of the branches of the aortic arch. Am ] Surg 1 9 6 9 ; 1 1 8 : 236-243. BLEICHROOTRP, BOONTJEAH. Surgical treatment of the subclavian steal syndrome by the transthoracal approach. VASA 1 9 8 4 ; 1 2 : 254-257. CRAWFOROES, STOWECL, POWERSJR RW. Occlusion of the innomihate, c o m m o n carotid, and subclavian arteries: Long-term results of surgical treatment. Surgery 1983; 94: 7 8 1 - 7 9 1 . THEVENETA. Surgical m a n a g e m e n t of atheroma of the aortic dome and origin of supra-aortic trunks. World J Surg 1979; 3 : 1 8 7 - 1 9 5 . VOGTDP, HERTZERNR, O'HARA PJ, et al. Brachio-cephalic arterial reconstruction. Ann Surg 1982 ; 196: 5 4 1 - 5 5 2 . BEEBEHG, STARKR, JOHNSONML et al. Choices of operation for subclavian-vertebral arterial disease. Am J Surg 1980; 139: 6 1 6 - 6 2 3 . WELLING RE, CRANLEYJJ, KRAUSER] et al. Obliterative arterial disease of the upper extremity. Arch Surg 1981 ; 116: t 5 9 3 - 1 5 9 6 . FINKELSTEINNM, BYERA, RUSH BF JR. Subclavian-subclavian bypass for the subclavian steal syndrome. Surgery 1972; 71 : 142-145. POSNER MP, RILES T8, RAMIREZAA et al. Axfllo-axillary bypass for symptomatic stenosis of the subclavian artery. Am ] Surg 1983: 145: 6 4 4 - 6 4 6 . PAr~OTr JC. The Subclavian Steal Syndrome. Arch Surg 1 9 8 4 ; 8 8 : 661-665. EowAmoS WH, WRmHT R8. Surgical therapy in subclavian occlusive disease. Am ] Surg 1972 ; 123: 6 8 9 - 6 9 3 . HUNTERG, PALMAZJC, CARSON SN, LANTZ MT. Surgically induced carotid subclavian steal syndrome. Arch Surg 1 9 8 3 ; 1 1 8 : 1 3 2 5 1329. OTIS S et al. Carotid steal syndrome following carotid subclavian bypass. ] Vast Surg 1984; 5: 6 4 9 - 6 5 2 .
Received 3 March 1987
Direct Subclavian-Carotid Anastomosis for the Subclavian Steal
Syndrome S e p p W e i m a n n 1, H a n s W i l l e i t 2 a n d G e r h a r d Flora 1 1 From the Departments of Vascular Surgery and 2 Neurology, Innsbruck University, Anichstrasse 35, A 6 0 2 0 Innsbruck, Austria Between 1984 and 1986, 38 patients--25 males and 13 females--underwent treatment for proximal subclavian arteriosclerotic lesions. All of these patients presented with syrr~ptoms of the subclavian steal syndrome and 13 (34.2%) had additional claudication of the arm. Preoperative angiography showed distal filling of the subclavian artery via retrograde flow in the vertebral artery. 31 patients (81.5%) had total occlusion of the proximal subclavian artery and 7 (18.5%) presented with severe stenosis. 34 of these lesions were on the left (89.5%) and 4 on the right side (10.5%). Complete cerebral angiography was performed in each patient with emphasis on visualisation of the carotid bifurcation and selective opacification of the aortic arch vessels if indicated. Doppler ultrasound flow measurement in the vertebral artery yielded the basic data which were then used for comparative postoperative evaluation. The operation was performed under general anaesthesia and heparinisation. A shunt was not required while performing the direct end-to-side anastomosis between the transected subclavian and the common carotid artery, Arteriosclerotic plaques in the distal stump of the transected subclavian artery and occasionally the origin of the vertebral artery were dealt with by simple eversion endarterectomy. There was no operative mortality; the postoperative complication rate was 13.1% including palsy of the recurrent nerve in 3 patients, a lymphatic cyst of the neck in one patient and bleeding requiring re-exploration in another. Occlusion of the reconstructed artery or neurologic deficit did not occur. Post operatively all patients were treated with platelet inhibitors. The average follow-up period was 13 months, when the reconstructed arteries were found to be patent in 37 patients (97.4%). In all patients, relief of the previously existing symptoms of the subclavian steal syndrome and arm claudication occurred. The 1-year results of this procedure are very satisfactory and in our department subclavian carotid transposition has therefore become the method of choice in the surgical treatment of the subclavian steal syndrome. Key Words: Subclavian artery; Common carotid artery; Subclavian steal syndrome; Subclavian artery occlusion; Subclavian carotid transposition; Arm claudication.
Introduction
A great variety of operative techniques have been described to m a n a g e obstructive lesions of the proximal subclavian artery. Most of these techniques have however some disadvantages: transthoracic subclavian endarterectomy and aorto-subclavian bypass surgery require a thoracotomy which m a y entail significant mortality and complication rates t,2 and carotid subclavian bypass grafting 3,4 requires two anastomoses which rePlease address reprint requests to: Sepp Weimarm, Department of Vascular Surgery, Innsbruck University, Anichstrasse 35, A 6020 Innsbruck, Austria. 0950-821X/87/050305 + 06 $03.00/0
© 1987 Grune & Stratton Ltd
quires clamping of the carotid artery. Another disadvantage of this procedure is that residual occlusive disease must often be left in the proximal subclavian artery and at the origin of the vertebral artery, thus limiting the potential improvement in cerebral perfusion. Other extra anatomic techniques, such as axillary-axillary bypass, do not require clamping of the carotid artery but have yielded unsatisfactory long-term patency and should therefore be reserved for high-risk patients with advanced systemic disease. The procedure of choice should be an extrathoracic approach, in which prosthetic grafts can be avoided, carotid occlusion minimised, and perfusion of the brain and upper extremities improved by re-establishing ante-
306
S. Weimann e t al.
Fig. 1. Duplexpulsed Dopplerultrasound tomography (7.5 MHZB-Scan, 3 MHZDoppler)of the left vertebral artery in a 63-year-oldmale patient presenting with total occlusion of the left proximal subclavian artery. Sagittal 13-mode display identifies the left ventebral artery, reversal of the waveformin Dopplerfrequencyanalysis indicates subclavian-steal-syndrome.
grade flow into the vertebral artery via a single end-toside anastomosis. Therefore direct anastomosis between the distal end of the divided proximal subclavian artery and the common carotid artery is now widely used in the treatment of patients with proximal subclavian occlusion. s, 6,7 We report here our experience with this method over the past 2 years.
M a t e r i a l s and M e t h o d s
Thirty-eight patients, 25 males and 13 females aged thirty-five to seventy-nine, were treated at the Department of Vascular Surgery, Innsbruck University, Austria. All of them presented with symptoms of the subclavian steal syndrome and 13 had additional exercise-related symptoms in the upper extremities. The left side was involved in 34 patients and the right side in four patients. Each patient was subjected to a thorough physical examination, including Duplex pulsed Doppler ultrasound tomography and Doppler frequency analysis to evaluate the direction of flow in the vertebral artery. Pre-operative Duplex examination showed reversed flow in the vertebral artery in all cases (Fig. 1). Furthermore arteriography was performed in 27 patients showing complete occlusion of the left subclavian artery (Fig. 2) which was bilateral in tbur patients. Seven patients presenting with sclerotic stenosis of the left subclavian artery also had obstruction of the opposite side. Two patients were of Eur ] Vasc Surg Vol 1, October 1987
great interest since there was an additional severe contralateral stenosis of the carotid bifurcation and they first had to undergo reconstruction of the carotid bifurcation.
Operative technique A supraclavicular transverse incision is made 1 cm above and parallel to the clavicle. The clavicular head and sometimes the entire sternocleidomastoid muscle is transected. We do not divide the anterior scalene muscle. Dissection of the proximal part of the subclavian artery is performed to facilitate exposure of the internal m a m m a r y artery which is sometimes ligated, Finally the origin of the vertebral artery is identified. Upon completion of the dissection, the origin of the subclavian artery from the aortic arch can be visualised so that a small clamp can be applied. Subsequently the common carotid artery is exposed over a length of approx 4 cm, carefully preserving the vagus nerve and the lymphatics entering the internal jugular vein; the proximal portions of the subclavian and common carotid arteries are frequently very close together. At this point in time the patient is fully heparinised; and the subclavian artery transected close to the aortic arch and the proximal stump is oversewn or ligated with 3/0 monofflament sutures. In some patients presenting with dense arteriosclerotic plaques in the peripheral stump of the subclavian artery extending into the orifice of the vertebral artery, endarterectomy
Direct Subclavian-Carotid Anastomosis
307
Fig. 2. Preoperative angiogram in a 42-year-old femalepatient showing total occlusion of the proximal left subclavian artery and filling of the left peripheral subclavian artery by retrograde left vertebral artery flow.
m a y be needed. Subsequently great care is taken to choose an area for the anastomosis between the end of the transected subclavian artery and the side of the common carotid artery so that kinking or angulation can be avoided. The carotid artery is then incised longitudinally on its lateral aspect and the anastomosis is performed using 6/0 monofllament running sutures (Fig. 3). No internal shunt is required; the average time of carotid clamping in our patients was 14 min. Before removal of the occluding clamps, vessels are flushed in order to remove air and clots. Then blood flow is first diverted into the a r m and then into the cerebral vessels. The wound is closed in layers and drains inserted.
Results
All 38 patients made a satisfactory recovery and had complete remission of symptoms. The early complications included a lymphatic cyst of the neck in one patient, paresis of the recurrent nerve in three patients and bleeding in one patient. Oscillography and Doppler ultrasound flow measurements in the vertebral artery were performed at follow up demonstrating an antegrade flow in the ver= tebral artery in all patients (Fig. 4). Postoperative angiography was performed in six patients and showed a satisfactory result in all of them (Fig. 5). Postoperatively all patients were given antiplate= EurJ Vasc Surg Vol 1. October 1987
308
S. W e i m a n n e t al.
Fig. 3. Intraoperative view: the transected left subclavian artery is anastomosed to the side of the left common carotid artery. Same patient as shown in Fig. 2.
]Fig. 4. Duplex ultrasound display of the left vertebral artery following subclavian-carotid transposition. Antegrade flow is indicated by an upward amplitude in systolic and diastolic phase. Same patient as shown in Fig. 1. Eur ] Vasc Surg Vol 1, October 19 8 7
Direct Subclavian-Carotid Anastomosis
Fig. 5. Postoperative arch angiogram of the patient shown in Fig. 1, taken 6 days after left subclavian-carotidtransposition. Antegradeflow is present in the left vertebral artery.
let drugs. The average follow-up period was 13 months, during this time the reconstructed arteries were found to be patent in 37 patients. There was no operative mortality.
Discussion Occlusive disease of the proximal subclavian artery may cause severe ischaemia of the upper extremities or the subclavian steal syndrome. The Joint study documented left subclavian stenosis in 8.3% and occlusions in 0.8% 8 of cases. Since m a n y patients are asymptomatic, operative intervention is not necessary in all patients in w h o m arteriography reveals a lesion of the subclavian artery. Selection for operation is therefore based on clinical features rather than on angiographic findings. When treatment is required, total occlusion of the subclavian artery requires surgery, whereas a stenosis can be suc-
309
cessfufly dilated by percutaneous transluminal angioplasty2 Contorni TM and Reivich 11 were the first to report on the reversal of the blood flow through the vertebral artery and its effects on the cerebral circulation. At that time the term "subclavian steal" was coined and the surgical management of this syndrome has led to the development of a number of operative techniques. A transthoracic approach with endarterectomy or bypass techniques yield very satisfactory clinical results but early reports quoted a mortality rate of 9 to 20%. 1,12 Although the mortality after transthoracic repair of occlusive lesions of the left subclavian artery is now much less because of increasing experience, improved anaesthesia and better patient selection, 2,t3-16 the early mortality mentioned above led to the use of extraanatomic bypass procedures,3,17 such as carotid subclavian bypass, TM subclavian-subclavian bypass, 19 axillo-axillary bypass 2° and direct subclavian carotid anastomosis, s Of these procedures carotid subclavian and carotid axillary bypass using saphenous vein or Dacron grafts have enjoyed the greatest popularity. 3,4 In comparison to other procedures direct subclavian-carotid anastomosis, as first reported by Parrot 21 and Edwards 22 has several advantages. No graft is necessary and a single anastomosis is all that is needed. The anastomosis produces antegrade flow which is haemodynamically more satisfactory. Prior to operation it is however important to investigate the carotid circulation by means of angiography. Obstructive lesions of the common carotid artery proximal to the proposed site of anastomosis would cause a reduced inflow and distal lesions would result in a "carotid steal" phenomenon. Blood flow measured at operation was reduced by 20% in the peripheral common carotid artery in our patients but no evidence of carotid steal was detected. 7 Surgically induced carotid steal has however been observed but only following carotid subclavian bypass surgery3 T M If a carotid lesion is detected on preoperative investigation it must be repaired either before dealing with the subclavian occlusion--as was necessary in two of our cases--or simultaneously. In our opinion there is no need for cerebral protection with a shunt during the procedure, and none were used in this series. There were no neurological complications. In contrast Mehigan 6 used an intraluminal shunt when the stump pressure was found to be less than 50 mmHg. Early occlusion of the reconstructed arteries has not been seen in this series. Complete relief of preoperative symptoms of vertebrobasilar insufficiency and claudication of the arm was achieved in all cases. Doppler ultrasound flow measurements in the vertebral artery, arm osciUography and in some cases angiography were per= formed at follow-up to confirm restoration of normal flow Eur] VascSurg Vol 1, October 1987
310
S. W e i m a n n e t al.
in the vertebral artery after surgery. Duplex scanning is of great value both in the diagnosis and follow-up of these patients. It is possible to identify the diameter of the vertebral artery and frequency analysis of the waveform in patients presenting with Subclavian Steal Syndrome shows the typical changes of decreased peak, widening of systolic amplitude and missing diastolic backflow. The importance of antiplatelet agents in these patients remains unresolved. Suffice to say that we used them in all our cases with a 2 year patency of 9 7%.
10
11
12
]3
14
References 1 CRAWVORDES, DE BAKEYME, MORRIS GC, HOWELLJF. Surgical treatm e n t of occlusion of the innominate, c o m m o n carotid, and subclavian arteries: a 10 year experience. Surgery 1969; 6 5 : 1 7 - 3 1 . 2 GRtra JD. Extra- u n d transthorakales Vorgehen beim Subclavian Steal Syndrom. Langenbecks Arch Chir 1975; 339: 704. 3 MOOREWS, MALONE]S, GOLDSTONEJ. Extrathoracic repair of branch occlusions of the aortic arch. Am ] Surg 1976; 132 : 2 4 9 - 2 5 3 . 4 PIERANDOZZIJS, INGALAA, COWEEN8W. Proximal subclavian artery occlusion. Arch Surg 1975 ; 1 1 0 : 1 2 6 - 1 3 0 . 5 DIETHRICH EB, KOOPOT R. Simplified operative procedure for proximal subclavian arterial lesions: direct subclavian-carotid anastomosis. Am ] Surg 1981 ; 142 : 4 1 6 4 2 1 . 6 MEHIGANJT, BUCH WS, PIPKIN RD, FOGARTYTJ. Subclavian-carotid transposition for the sublcavian steal syndrome. Am ] Surg 1978; 136:15-20. 7 SANDMANNW, KREMERK, LERUT], HENNERICI M, AULICHA. Subclavia-carotis-transposition zur Behandiung der Subclavia-verschlul~erkrankung mit Anzapfsyndrom. Chirurg 1980; 51 : 2 2 8 - 2 3 4 . 8 FIELDSWS, LEMAKNA. Joint study of extracranial arterial occlusion. VII subclavian s t e a l - - a review of 168 cases, lAMA 1 9 7 2 ; 2 2 2 : 1139-1143. 9 MOTARJEME A, KEIFER JW, ZUSKA AJ, NABAWI, P. Percutaneous
EurJ Vase Surg Vol 1, October 1987
15 16 17 18 19 20
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transluminal angioplasty for treatment of subclavian steal. Radiology 1 9 8 5 ; 1 5 5 : 6 1 1 - 6 1 3 . CONTORNIL. Il circolo collaterale vertebro-vertebrale nella obliterazione dell'arteria succlavia alia sua origine. Minerva Chir 1 9 6 0 ; 1 5 : 268-271. REIVICHM, HOLLINGHE, ROBERTSB, TOOLEJF. Reversal of blood flow t h r o u g h the vertebral artery and its effect on cerebral circulation. N Engl J Med 1 9 6 1 ; 2 6 5 : 8 7 8 - 8 8 5 . EHRENFELDWK, CHAPMANRD, WYLIE EJ. M a n a g e m e n t of occlusive lesions of the branches of the aortic arch. Am ] Surg 1 9 6 9 ; 1 1 8 : 236-243. BLEICHROOTRP, BOONTJEAH. Surgical treatment of the subclavian steal syndrome by the transthoracal approach. VASA 1 9 8 4 ; 1 2 : 254-257. CRAWFOROES, STOWECL, POWERSJR RW. Occlusion of the innomihate, c o m m o n carotid, and subclavian arteries: Long-term results of surgical treatment. Surgery 1983; 94: 7 8 1 - 7 9 1 . THEVENETA. Surgical m a n a g e m e n t of atheroma of the aortic dome and origin of supra-aortic trunks. World J Surg 1979; 3 : 1 8 7 - 1 9 5 . VOGTDP, HERTZERNR, O'HARA PJ, et al. Brachio-cephalic arterial reconstruction. Ann Surg 1982 ; 196: 5 4 1 - 5 5 2 . BEEBEHG, STARKR, JOHNSONML et al. Choices of operation for subclavian-vertebral arterial disease. Am J Surg 1980; 139: 6 1 6 - 6 2 3 . WELLING RE, CRANLEYJJ, KRAUSER] et al. Obliterative arterial disease of the upper extremity. Arch Surg 1981 ; 116: t 5 9 3 - 1 5 9 6 . FINKELSTEINNM, BYERA, RUSH BF JR. Subclavian-subclavian bypass for the subclavian steal syndrome. Surgery 1972; 71 : 142-145. POSNER MP, RILES T8, RAMIREZAA et al. Axfllo-axillary bypass for symptomatic stenosis of the subclavian artery. Am ] Surg 1983: 145: 6 4 4 - 6 4 6 . PAr~OTr JC. The Subclavian Steal Syndrome. Arch Surg 1 9 8 4 ; 8 8 : 661-665. EowAmoS WH, WRmHT R8. Surgical therapy in subclavian occlusive disease. Am ] Surg 1972 ; 123: 6 8 9 - 6 9 3 . HUNTERG, PALMAZJC, CARSON SN, LANTZ MT. Surgically induced carotid subclavian steal syndrome. Arch Surg 1 9 8 3 ; 1 1 8 : 1 3 2 5 1329. OTIS S et al. Carotid steal syndrome following carotid subclavian bypass. ] Vast Surg 1984; 5: 6 4 9 - 6 5 2 .
Received 3 March 1987