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Occlusive disease of the common carotid and subclavian arteries treated by carotid-subclavian bypass
Occlusive
Disease
and Subclavian
of the Common Arteries
Carotid-Subclavian
Carotid
Treated
by
Bypass*
Analysis of 125 Cases EDWARD B. DIETHRICH, M.D.,H. EDWARD GARRETT, M.D.,JOSE AMERISO, M.D., E.STANLEY CRAWFORD,M.D.,~~AHMOUD EL-BAYAR,M.D.,ANDMICHAEL E.DE BAKEY,M.D.,
Houston, Texas
From &heCora and Webb A4ading Department of Surgery, Baylor University College of Medicine, Houston, Texas. This work was supported in part by U.S.P.H.S. Grants No. HE&5435 and GRS-P-6714.
OCCLUSIVE LESIONS of the A THEROSCLEROTIC great vessels arising from the aortic arch
have been treated by a variety of operations [1,2] including bypass graft from the ascending aorta to the common carotid or subclavian arteries, localized endarterectomy with or without patch graft angioplasty, and carotid-subclavian bypass. When the occlusive lesion occurs at the origin of either the common carotid or subclavian arteries, a carotid-subclavian bypass has provided a relatively simple and highly effective method of restoring circulation beyond the area of obstruction. Since our initial experience in 1953 with carotid artery operations, 125 patients have been treated with carotid-subclavian bypass procedures. An analysis of this experience constitutes the basis for this report. CLINICAL MATERIAL Of the 125 patients, seventy-three were men and fifty-two were women and their ages ranged from twenty-one to seventy-eight years with an average age of fifty years. Symptoms were related to cerebrovascular insufficiency of the carotid or vertebro-
basilar systems, upper extremity claudication, or a combination of these syndromes. The symptoms of vertebrobasilar insufficiency present in forty-nine patients (39.2 per cent) included vertigo, slight headaches, dizziness, double vision, garbled speech, tinnitus or hearing loss, and paresthesias or anesthesia. Those of upper extremity claudication present in twenty-one cases (16.8 per cent) included numbness and tingling, heaviness, coldness, aching and pain, blanching, and weakness. Symptoms of vertebrobasilar insufficiency present in thirty-cases (34 per cent) included varying combinations of the symptoms of both vertebrobasilar insufficiency and upper extremity claudication with precipitation by arm exercise. Those of carotid artery disease present in twenty-five cases (20 per cent) included unilateral dimming or blindness, contralateral weakness or paralysis, aphasia or dysphasia, focal or generalized seizures, and contralateral paresthesias or anesthesia. Each patient had a complete history and physical examination including a thorough neurologic evaluation. Arteriography was performed in all patients by either percutaneous bilateral carotid and subclavian puncture or retrograde aortic arch injection. (Fig. la and b.) Previous experience with cases of cerebrovascular insufficiency has indicated that history and physical examination are not entirely reliable in establishing the site of arterial disease [3,4]. The responsible and surgically correctable arterial lesion can be identified only by complete angiographic studies. In this series, multiple extracranial arterial lesions were encountered in 71 of the 125 patients (56.8 per cent).
* Presented at the Nineteenth Annual Meeting of the Southwestern Surgical Congress, Phoenix, Arizona, April 10-13, 1967. 800
American
Journal
of Surgery
Occlusive
a
Arterial
Disease
801
‘I
FIG. 1. Technic of four vessels cervical (a) and retrograde aortic arch angiography (b) used in preoperative study of patients with symptoms of cerebrovascular insufficiency, upper extremity claudication, or combination of these syndromes. Aortic arch angiography is indicated when an occlusive lesion at the origin of the great vessels is suspected by clinical examination. ARTERIOGRAPHIC OPERATIVE
PATTERNS AND TREATMENT
An appropriate angioplastic procedure was performed in each patient depending on the arteriographic findings. Of the forty-nine pa-
I
a
tients primarily with symptoms of vertebrobasilar insufficiency, arteriography demon&rated proximal right subclavian arterial ocelusive disease in five. An example of occlusion of the right subclavian artery at its origin from
d
FIG. 2. (a) Drawing of arterial disease pattern illustrates occlusion of right subclavian artery proxima1 to the origin of the right veretebral artery. (b) Retrograde aortic arch angiogram shows occlusion of proximal right subclavian artery. (c) Left subclavian arteriogram shows retrograde blood flow in right vertebral artery typical of right “subclavian steal” phenoml enon. (d) Drawing illustrates restoration of normal circulation using Dacron bypass graft from r-ight common carotid to right subclavian artery. Patient has remained asymptomatic five years al‘ter operation. Vol. 114. November
1967
Diethrich et al.
60.
LEFT
SUBCLAVIAN
FIG. 3. Drawing (a) and retrograde aortic arch angiogram (b) illustrate high grade stenosis of left subclavian artery. A 30 mm. Hg pressure gradient was demonstrated at operation. (c) Drawing illustrates Dacron bypass graft from the left common carotid to left subclavian artery with restoration of normal circulation to the upper extremity and abolishment of pressure gradient between carotid and subclavian arteries.
FIG. 4. (a) Drawing illustrates arterial occlusive pattern with obstruction of proximal left subclavian artery, and 30 mm. Hg pressure gradient between left common carotid and subclavian arteries. (b) Retrograde aortic arch angiogram illustrates occlusion of left subclavian artery with early retrograde flow in left vertebral artery. (c) Delayed roentgenogram shows complete retrograde filling of left vertebral artery proximal to the subclavian artery obstruction. (d) Drawing illustrates bypass graft from left common carotid artery to left subclavian artery with abolishment of pressure gradient. (e) Retrograde aortic arch angiogram three years after operation shows patency of bypass graft.
American Journal
of Surgery
Occlusive Arterial Disease
803
f
a FIG. 5. (a) Drawing illustrates arterial occlusive pattern with complete ob&ruction of the right common carotid artery in a patient exhibiting symptoms of carotid artery disease. (b) Right subclavian arteriogram shows patency of right carotid artery bifurcation through collateral circulation despite complete occlusion of the common carotid artery. (c) Drawing illustrates restoration of normal cerebral blood flow using a bypass graft from the right subclavian artery to the bifurcation of the right common carotid ke&I
the innominate artery with retrograde blood flow in the right vertebral artery is illustrated in Figure 2. This patient’s symptoms of vertigo, dizziness, and paresthesia were abolished after right carotid-subclavian bypass. Proximal left subclavian arterial occlusive disease was encountered in forty-four patients. There was an associated occlusive lesion of the carotid artery in five patients and of the vertebral artery in two patients. A Dacron@ bypass graft from the left common carotid to left subclavian artery was performed in forty-four patients and from the right common carotid to the right subclavian artery in five patients. Concomitant thromboendarterectomy with Dacron patch graft angioplasty of the carotid artery bifurcation and vertebral endarterectomy with Dacron patch graft angioplasty were performed in those patients with associated lesions. Of the twenty-one patients presenting with symptoms of upper extremity claudication, arteriography demonstrated occlusive disease of the proximal right subclavian artery in three and of the proximal left subclavian artery in Vol. 114. November 1967
eighteen. An example of obstruction of the proximal left subclavian artery in a patient with left arm claudication is illustrated in Figure 3. This patient was treated with a bypass graft from the left common carotid to the left subclavian artery with elimination of the pressure gradient and claudication symptoms. A similar Dacron bypass graft from the appropriate common carotid to the subclavian artery was performed in the remaining patients. Of the thirty patients with combined symptoms of vertebrobasilar insuffciency and upper extremity claudication, a proximal right subclavian occlusive lesion was presented in four and a proximal left subclavian lesion in twentysix. An example of obstruction of the proximal left subclavian artery in a patient with combined symptoms is illustrated in Figure 4. There was an additional lesion of the carotid bifurcation in four patients and a vertebral lesion in four patients. A bypass graft from the common carotid to subclavian artery was performed with the associated carotid and vertebral lesions corrected by appropriate angioplastic procedures.
804
Diethrich
et al.
FIG. 6. Operative
in sixteen. An example of occlusion of ma1 right common carotid artery with tion of a patent bifurcation through and retrograde flow is illustrated in These patients were treated using
Of the twenty-five patients with symptoms primarily of carotid artery disease, arteriographic studies demonstrated occlusive disease of the proximal right common carotid in nine and of the proximal left common carotid artery TABLE ANALYSIS
OF IMMEDIATE
AND
LONG-TERM
RESULTS
I. Vertebrobasilar insufficiency II. Upper extremity claudication III. Combined vertebrobasilar insufficiency and upper extremity claudication IV. Carotid artery disease
BYPASS
Results
Hospital Deaths (6; 4.3%)
Remission of Symptoms
49 21
2 1
46 19
30 25
1 2
29 23
No. of Patients (125)
the proxiopacificacollateral Figure 5. a bypass
I
OF CAROTID-SUBCLAVIAN
Immediate
Symptoms
technic of carotid-subclavian
IN
125
PATIENTS
Long-Term
Results
Recurrence of
Continued Remission of Symp-
Deaths
1 1
4 3
39 14
3 2
0 0
0 1
26 19
3 3
Sywtams Unchanged
American
Journal
of Surgery
Occlusive
bypass.
Arterial
Disease
805
See text for detailed description.
graft from the subclavian artery to the bifurcation of the common carotid artery. This was often accompanied by thromboendarterectomy of the carotid bifurcation. RESULTS
There has been a 100 per cent follow-up study of the 125 patients extending from nine months to fourteen years. The results have been divided into immediate, within the first postoperative month, and long-term, nine months or longer. (Table I.) An operative result was considered good if the patient experienced complete remission of symptoms. If the symptoms were aggravated by operation or if significant complications occurred, the result was considered poor. In a few patients the symptoms were unchanged after operation and were appropriately recorded. The operative mortality was 4.8 per cent in this series. Vol. 114, November
1967
Of forty-nine patients with symptoms primarily of vertebrobasilar insufficiency, two patients died of myocardial infarction in the postoperative period. One patient’s condition was unchanged. Forty-six patients had an immediate good result. Long-term results were considered good in thirty-nine patients, with four patients having recurrence of symptoms, one due to graft occlusion at four months. One patient died at eight months from complications of an infected graft, and two patients, both of whom were free of symptoms, died at four months and three years of myocardial infarction. In the group of thirty patients with combined symptoms of vertebrobasilar insufficiency and upper extremity claudication, the immediate results were good in twenty-nine. One patient died on the tenth postoperative day from a cerebral hemorrhage. Long-term results were good in twenty-six patients. Three patients
Diethrich et al.
FIG. 7. (a) Drawing of arterial disease pattern illustrates occlusion of proximal left subclavian artery. (b, c, d, and e) Injection of contrast material into left common carotid artery with serial films shows complete retrograde filling of left vertebral and subclavian arteries from the left external carotid artery. This represents a form of “carotid artery steal.” (f) Drawing illustrates restoration of normal circulation with bypass graft from left common carotid to subclavian artery.
died, one of hepatitis at six months, one of a cerebrovascular accident at eighteen months, and the other of lung carcinoma at two years. The grafts were functioning well in these three patients and they were asymptomatic prior to death. Of the twenty-one patients treated for upper extremity claudication, the immediate results were good in nineteen. A false aneurysm developed in one patient eleven days postoperatively and on long-term follow-up study the patient continued to have claudication. One patient died from an acute cerebrovascular accident which developed on the fifth postoperative day. Of the remaining nineteen patients, fourteen are free of symptoms. Two patients were asymptomatic until death from myocardial infarction, one and two years postoperatively. In three patients there has been a recurrence of symptoms despite a functioning graft and good distal pulses. Of the twenty-five patients treated for symptoms of carotid artery disease, twenty-three were considered to have immediate good results. One patient died on the fifth postoperative day of myocardial infarction. Another died of uremia five weeks postoperatively. Nineteen patients have continued to be free of symptoms. Three patients have died, one at three months, another at eighteen months, and one at three years, all from myocardial infarction. They
were free of symptoms prior to death. One patient had recurrence of symptoms six years after operation despite a functioning graft. TECHNIC OF CAROTID-SUBCLAVIAN
BYPASS
With the patient in the supine position and the head rotated slightly toward the opposite side, a transverse supraclavicular incision is made. (Fig. 6, Inset.) The subcutaneous tissue, platysma muscle, and clavicular head of the sternocleidomastoid muscle are incised. The sternal head of the sternocleidomastoid muscle is retracted medially and the common carotid artery exposed and encircled with umbilical tape. (Fig. 6a.) The scalenus anticus muscle is transected after isolating the overlying phrenic nerve. The subclavian artery is exposed, dissected free, and encircled with heavy silk ligatures. (Fig. 6b.) Pressures are measured in the common carotid artery and the subclavian artery to demonstrate the gradient. (Fig. 6c.) The common carotid artery is clamped and incised and a polyethylene internal shunt inserted for continuous cerebral perfusion during suturing of the graft. (Fig. 6d, e, and f.) An 8 mm. knitted Dacron graft is sutured end to side to the common carotid artery using No. 4-O polyethylene* suture material. The graft is preclotted, the internal shunt removed, sutures *Manufactured by Davis & Geck Co., Danbury,
Connecticut.
American Journal of Surgery
Occlusive
Arterial
tied, and the graft cross-clamped just beyond the anastomosis. (Fig. 6g, h, and i.) The subclavian artery is clamped proximally and distally and is incised, and the Dacron graft anastomosed end to side using similar suture material. Prior to completing the distal anastomosis, adequate flushing is accomplished to assure evacuation of any clots. (Fig. Sj and k.) Upon completing the bypass, pressure measurements are again recorded to demonstrate elimination of the gradient. (Fig. 61.) The bypass graft may be brought over, as illustrated in Figure 6, or beneath the internal jugular vein depending on the anatomic variations in the neck. The wound is closed in layers. An autogenous vein may be used for the bypass graft as was done in five cases in this series. COMMENTS
The underlying pathologic lesion in all cases was an obstructing atheromatous plaque; however a congenital cause has been reported in other cases [5,6]. The affected artery was either occluded as illustrated in Figure 2 or stenosed as illustrated in Figure 3. The result was a reduction of blood flow accounting for the symptoms of cerebrovascular insufficiency, upper extremity claudication, or combinations of these symptoms. As anticipated, when the carotid artery was involved, the symptoms were primarily those of anterior cerebral ischemia. When the obstructing lesion was in the subclavian artery proximal to the origin of the vertebral artery, symptoms were variable depending on the changes in blood flow which occurred [5]. A decrease in vertebral artery perfusion may result in a blood flow deficit to the vertebrobasilar circulation. The severity of this depends on the adequacy of the opposite vertebral artery to cross fill through the basilar artery communication. A true reversal of flow in the vertebral artery may occur so that blood is siphoned from the brain down the vertebral artery into the subclavian artery as first described by Contorni in 1960 [7]. This phenomenon is known as the subclavian steal syndrome [8,Y] or brachialbasilar insufficiency syndrome [IO]. Symptoms in these patients were often precipitated or aggravated by upper extremity movement when demand for blood in the arm and shoulder regions was sufficient to lower flow through the basilar artery below a critical level. In cases of obstruction of the proximal subclavian artery, blood is not always siphoned Vol. 114, November
1967
Disease
from the contralateral vertebral artery through the basilar artery as was illustrated in Figure 2. A “steal” of blood may occur from the carotid artery system as illustrated in Figure 7 in which contrast material injected into the left common carotid artery fills the left vertebral and subclavian arteries through branches of the external carotid artery. In cases of proximal occlusion or stenosis of the innominate artery, the carotid-subclavian bypass is not applicable and a bypass graft from the ascending aorta to the right subclavian and carotid arteries is employed. The establishment of a bypass between the carotid and subclavian arteries raises the possibility of creating a carotid “steal,” thereby producing carotid insufficiency. There has been no clinical evidence of such a phenomenon in any of our patients. The effectiveness of the bypass graft between the carotid and subclavian arteries is demonstrated by the high percentage of favorable results in this group. The importance of associated occlusive lesions of the carotid and vertebral arteries should be emphasized since correction of these disease processes combined with the bypass procedure further enhances the opportunity for remission of symptoms [ll]. Complete angiographic studies are required to delineate the site or sites of the arterial occlusive lesions. SUMMARY
Carotid-subclavian bypass has been employed in the treatment of cerebrovascular insufficiency, upper extremity claudication, or a combination of these syndromes in 125 patients. All patients were studied angiographically prior to operation with either bilateral carotid and subclavian puncture or retrograde aortic arch injection. Indications for carotid subclavian bypass operation included : upper extremity claudication, twenty-one cases; symptoms of vertebrobasilar insufficiency, forty-nine cases; upper extremity claudication combined with symptoms of vertebrobasilar insufficiency, subclavian steal syndrome, and brachial-basilar insufficiency syndrome, thirty cases; symptoms of cerebrovascular insufficiency due to an obstructing lesion at the origin of the carotid arteries, twentyfive cases. Left carotid-subclavian bypass was employed in ninety-one patients (72 per cent) and right
808
Diethrich
carotid .subclavian bypass in twenty (10 per cent). In fourteen patients (11 per cent) thromboendarterectomy of the common carotid bifurcation accompanied the carotid-subclavian bypass. There’was an operative mortality of 4.8 per cent in this series of 125 patients. Follow-up studies obtained on all patients extending from nine months to fourteen years have dcmonstrated the effectiveness of this method of operative treatment. REFERENCES
et al. 4. DE BAKEY, M. E.. DIE,L‘IIRIC~, E. V., GARRETT, H. E., and MCCUTCHEN. J. J. Surgical treatment of cerebrovascular disease. Postpzd. Med., in
press. 5. MASSUMI, R. A. Tile congenital
6.
7. 8.
1. CRAWFORD, E. S., DE BAKEY, M. E., MORRIS, G. C., JR., and COOLEY, D. A. Thrombo-oblitera-
tive disease of the great vessels arising from the aortic arch. _I. Thhoracrc6 Cardiavasc. Surg., 43: 38, 1962.
2. KILLEN, D. A., FOSTER, J. H., GOBBEL, W. G., STEPHENSON, S. E., JR., COLLINS, G. A., BIL-
LINGS, F. T., and SCOTT, H. W., JR. The subclavian steal syndrome. J. Thora& & Cardiovax. ,%7x., 51: 539, 1966. 3. DE BAKEY, M. E. Concepts UnderIying Surgical Treatment of Cerebrovascular Insufficiency. In : Clinical Neurosurgery, chapt. 17, p. 310. Baltimore, 1964. Williams & Wilkins Co.
9. 10.
11.
variety of the “subclavian steal” syndrome. Circulalion, 28: 1149, 1963. LEVINE, S., SERFAS, L. S., and KUSINK~. A. Right aortic arch with subclavian steal syndrome (atresia of left common carotid and left subclavian arteries). Am. J. Surg., 111: 632, 1966. CONTORNI, L. 11 circolo collaterale vertebrovertebrale nella obliterazione dell’arterial succlavia alla sue origine. Minerva chir., 15: 268, 1960. REIVICH, M., HOLLING, H. E., ROBERTS, B., and TOOLE, J. F. Reversal of blood flow through vertebral artery and its cffcct on crrebral circulation. New England J. Med., 265: 878, 1961. Editorial. A new vascular syntlrou~e: “The subclavian steal.” Nerc England J. Med., 265: 912, 1961. NORTH, R. R., FIELDS, W. S., DE BAKEY, M. E., and CRAWFORD, E. S. Brachial-basilar insufliciency syndrome. Nez~rdogy, 12: 810, 1962. CRAWFORD, E. S., DE BAKEY, M. E., BLAISDELL, F. W., MORRIS, G. C., JR., and FIELDS, W. S.
Hemodynamic alterations in patients with cerebral arterial insuff%ency bvfore and after operation. Szlrgery,48: iii, 1960.
Correction In the article, “A Study of Disposable Surgical Masks,” by Drs. Paul 0. Madsen and Renate E. Madsen, which appeared on page 431 of the September issue of the Journal, the trade name given far the cellulose fiber paper mask as well as the manufacturer of this product were incorrectly designated as the Paper Mask manufactured by C. R. Bard, Inc., Murray Hill, New Jersey. The correct trade name for this product is the Reitex paper mask manufactured by Edward Reitano Inc., Mt. Vernon, New York.
Disease
and Subclavian
of the Common Arteries
Carotid-Subclavian
Carotid
Treated
by
Bypass*
Analysis of 125 Cases EDWARD B. DIETHRICH, M.D.,H. EDWARD GARRETT, M.D.,JOSE AMERISO, M.D., E.STANLEY CRAWFORD,M.D.,~~AHMOUD EL-BAYAR,M.D.,ANDMICHAEL E.DE BAKEY,M.D.,
Houston, Texas
From &heCora and Webb A4ading Department of Surgery, Baylor University College of Medicine, Houston, Texas. This work was supported in part by U.S.P.H.S. Grants No. HE&5435 and GRS-P-6714.
OCCLUSIVE LESIONS of the A THEROSCLEROTIC great vessels arising from the aortic arch
have been treated by a variety of operations [1,2] including bypass graft from the ascending aorta to the common carotid or subclavian arteries, localized endarterectomy with or without patch graft angioplasty, and carotid-subclavian bypass. When the occlusive lesion occurs at the origin of either the common carotid or subclavian arteries, a carotid-subclavian bypass has provided a relatively simple and highly effective method of restoring circulation beyond the area of obstruction. Since our initial experience in 1953 with carotid artery operations, 125 patients have been treated with carotid-subclavian bypass procedures. An analysis of this experience constitutes the basis for this report. CLINICAL MATERIAL Of the 125 patients, seventy-three were men and fifty-two were women and their ages ranged from twenty-one to seventy-eight years with an average age of fifty years. Symptoms were related to cerebrovascular insufficiency of the carotid or vertebro-
basilar systems, upper extremity claudication, or a combination of these syndromes. The symptoms of vertebrobasilar insufficiency present in forty-nine patients (39.2 per cent) included vertigo, slight headaches, dizziness, double vision, garbled speech, tinnitus or hearing loss, and paresthesias or anesthesia. Those of upper extremity claudication present in twenty-one cases (16.8 per cent) included numbness and tingling, heaviness, coldness, aching and pain, blanching, and weakness. Symptoms of vertebrobasilar insufficiency present in thirty-cases (34 per cent) included varying combinations of the symptoms of both vertebrobasilar insufficiency and upper extremity claudication with precipitation by arm exercise. Those of carotid artery disease present in twenty-five cases (20 per cent) included unilateral dimming or blindness, contralateral weakness or paralysis, aphasia or dysphasia, focal or generalized seizures, and contralateral paresthesias or anesthesia. Each patient had a complete history and physical examination including a thorough neurologic evaluation. Arteriography was performed in all patients by either percutaneous bilateral carotid and subclavian puncture or retrograde aortic arch injection. (Fig. la and b.) Previous experience with cases of cerebrovascular insufficiency has indicated that history and physical examination are not entirely reliable in establishing the site of arterial disease [3,4]. The responsible and surgically correctable arterial lesion can be identified only by complete angiographic studies. In this series, multiple extracranial arterial lesions were encountered in 71 of the 125 patients (56.8 per cent).
* Presented at the Nineteenth Annual Meeting of the Southwestern Surgical Congress, Phoenix, Arizona, April 10-13, 1967. 800
American
Journal
of Surgery
Occlusive
a
Arterial
Disease
801
‘I
FIG. 1. Technic of four vessels cervical (a) and retrograde aortic arch angiography (b) used in preoperative study of patients with symptoms of cerebrovascular insufficiency, upper extremity claudication, or combination of these syndromes. Aortic arch angiography is indicated when an occlusive lesion at the origin of the great vessels is suspected by clinical examination. ARTERIOGRAPHIC OPERATIVE
PATTERNS AND TREATMENT
An appropriate angioplastic procedure was performed in each patient depending on the arteriographic findings. Of the forty-nine pa-
I
a
tients primarily with symptoms of vertebrobasilar insufficiency, arteriography demon&rated proximal right subclavian arterial ocelusive disease in five. An example of occlusion of the right subclavian artery at its origin from
d
FIG. 2. (a) Drawing of arterial disease pattern illustrates occlusion of right subclavian artery proxima1 to the origin of the right veretebral artery. (b) Retrograde aortic arch angiogram shows occlusion of proximal right subclavian artery. (c) Left subclavian arteriogram shows retrograde blood flow in right vertebral artery typical of right “subclavian steal” phenoml enon. (d) Drawing illustrates restoration of normal circulation using Dacron bypass graft from r-ight common carotid to right subclavian artery. Patient has remained asymptomatic five years al‘ter operation. Vol. 114. November
1967
Diethrich et al.
60.
LEFT
SUBCLAVIAN
FIG. 3. Drawing (a) and retrograde aortic arch angiogram (b) illustrate high grade stenosis of left subclavian artery. A 30 mm. Hg pressure gradient was demonstrated at operation. (c) Drawing illustrates Dacron bypass graft from the left common carotid to left subclavian artery with restoration of normal circulation to the upper extremity and abolishment of pressure gradient between carotid and subclavian arteries.
FIG. 4. (a) Drawing illustrates arterial occlusive pattern with obstruction of proximal left subclavian artery, and 30 mm. Hg pressure gradient between left common carotid and subclavian arteries. (b) Retrograde aortic arch angiogram illustrates occlusion of left subclavian artery with early retrograde flow in left vertebral artery. (c) Delayed roentgenogram shows complete retrograde filling of left vertebral artery proximal to the subclavian artery obstruction. (d) Drawing illustrates bypass graft from left common carotid artery to left subclavian artery with abolishment of pressure gradient. (e) Retrograde aortic arch angiogram three years after operation shows patency of bypass graft.
American Journal
of Surgery
Occlusive Arterial Disease
803
f
a FIG. 5. (a) Drawing illustrates arterial occlusive pattern with complete ob&ruction of the right common carotid artery in a patient exhibiting symptoms of carotid artery disease. (b) Right subclavian arteriogram shows patency of right carotid artery bifurcation through collateral circulation despite complete occlusion of the common carotid artery. (c) Drawing illustrates restoration of normal cerebral blood flow using a bypass graft from the right subclavian artery to the bifurcation of the right common carotid ke&I
the innominate artery with retrograde blood flow in the right vertebral artery is illustrated in Figure 2. This patient’s symptoms of vertigo, dizziness, and paresthesia were abolished after right carotid-subclavian bypass. Proximal left subclavian arterial occlusive disease was encountered in forty-four patients. There was an associated occlusive lesion of the carotid artery in five patients and of the vertebral artery in two patients. A Dacron@ bypass graft from the left common carotid to left subclavian artery was performed in forty-four patients and from the right common carotid to the right subclavian artery in five patients. Concomitant thromboendarterectomy with Dacron patch graft angioplasty of the carotid artery bifurcation and vertebral endarterectomy with Dacron patch graft angioplasty were performed in those patients with associated lesions. Of the twenty-one patients presenting with symptoms of upper extremity claudication, arteriography demonstrated occlusive disease of the proximal right subclavian artery in three and of the proximal left subclavian artery in Vol. 114. November 1967
eighteen. An example of obstruction of the proximal left subclavian artery in a patient with left arm claudication is illustrated in Figure 3. This patient was treated with a bypass graft from the left common carotid to the left subclavian artery with elimination of the pressure gradient and claudication symptoms. A similar Dacron bypass graft from the appropriate common carotid to the subclavian artery was performed in the remaining patients. Of the thirty patients with combined symptoms of vertebrobasilar insuffciency and upper extremity claudication, a proximal right subclavian occlusive lesion was presented in four and a proximal left subclavian lesion in twentysix. An example of obstruction of the proximal left subclavian artery in a patient with combined symptoms is illustrated in Figure 4. There was an additional lesion of the carotid bifurcation in four patients and a vertebral lesion in four patients. A bypass graft from the common carotid to subclavian artery was performed with the associated carotid and vertebral lesions corrected by appropriate angioplastic procedures.
804
Diethrich
et al.
FIG. 6. Operative
in sixteen. An example of occlusion of ma1 right common carotid artery with tion of a patent bifurcation through and retrograde flow is illustrated in These patients were treated using
Of the twenty-five patients with symptoms primarily of carotid artery disease, arteriographic studies demonstrated occlusive disease of the proximal right common carotid in nine and of the proximal left common carotid artery TABLE ANALYSIS
OF IMMEDIATE
AND
LONG-TERM
RESULTS
I. Vertebrobasilar insufficiency II. Upper extremity claudication III. Combined vertebrobasilar insufficiency and upper extremity claudication IV. Carotid artery disease
BYPASS
Results
Hospital Deaths (6; 4.3%)
Remission of Symptoms
49 21
2 1
46 19
30 25
1 2
29 23
No. of Patients (125)
the proxiopacificacollateral Figure 5. a bypass
I
OF CAROTID-SUBCLAVIAN
Immediate
Symptoms
technic of carotid-subclavian
IN
125
PATIENTS
Long-Term
Results
Recurrence of
Continued Remission of Symp-
Deaths
1 1
4 3
39 14
3 2
0 0
0 1
26 19
3 3
Sywtams Unchanged
American
Journal
of Surgery
Occlusive
bypass.
Arterial
Disease
805
See text for detailed description.
graft from the subclavian artery to the bifurcation of the common carotid artery. This was often accompanied by thromboendarterectomy of the carotid bifurcation. RESULTS
There has been a 100 per cent follow-up study of the 125 patients extending from nine months to fourteen years. The results have been divided into immediate, within the first postoperative month, and long-term, nine months or longer. (Table I.) An operative result was considered good if the patient experienced complete remission of symptoms. If the symptoms were aggravated by operation or if significant complications occurred, the result was considered poor. In a few patients the symptoms were unchanged after operation and were appropriately recorded. The operative mortality was 4.8 per cent in this series. Vol. 114, November
1967
Of forty-nine patients with symptoms primarily of vertebrobasilar insufficiency, two patients died of myocardial infarction in the postoperative period. One patient’s condition was unchanged. Forty-six patients had an immediate good result. Long-term results were considered good in thirty-nine patients, with four patients having recurrence of symptoms, one due to graft occlusion at four months. One patient died at eight months from complications of an infected graft, and two patients, both of whom were free of symptoms, died at four months and three years of myocardial infarction. In the group of thirty patients with combined symptoms of vertebrobasilar insufficiency and upper extremity claudication, the immediate results were good in twenty-nine. One patient died on the tenth postoperative day from a cerebral hemorrhage. Long-term results were good in twenty-six patients. Three patients
Diethrich et al.
FIG. 7. (a) Drawing of arterial disease pattern illustrates occlusion of proximal left subclavian artery. (b, c, d, and e) Injection of contrast material into left common carotid artery with serial films shows complete retrograde filling of left vertebral and subclavian arteries from the left external carotid artery. This represents a form of “carotid artery steal.” (f) Drawing illustrates restoration of normal circulation with bypass graft from left common carotid to subclavian artery.
died, one of hepatitis at six months, one of a cerebrovascular accident at eighteen months, and the other of lung carcinoma at two years. The grafts were functioning well in these three patients and they were asymptomatic prior to death. Of the twenty-one patients treated for upper extremity claudication, the immediate results were good in nineteen. A false aneurysm developed in one patient eleven days postoperatively and on long-term follow-up study the patient continued to have claudication. One patient died from an acute cerebrovascular accident which developed on the fifth postoperative day. Of the remaining nineteen patients, fourteen are free of symptoms. Two patients were asymptomatic until death from myocardial infarction, one and two years postoperatively. In three patients there has been a recurrence of symptoms despite a functioning graft and good distal pulses. Of the twenty-five patients treated for symptoms of carotid artery disease, twenty-three were considered to have immediate good results. One patient died on the fifth postoperative day of myocardial infarction. Another died of uremia five weeks postoperatively. Nineteen patients have continued to be free of symptoms. Three patients have died, one at three months, another at eighteen months, and one at three years, all from myocardial infarction. They
were free of symptoms prior to death. One patient had recurrence of symptoms six years after operation despite a functioning graft. TECHNIC OF CAROTID-SUBCLAVIAN
BYPASS
With the patient in the supine position and the head rotated slightly toward the opposite side, a transverse supraclavicular incision is made. (Fig. 6, Inset.) The subcutaneous tissue, platysma muscle, and clavicular head of the sternocleidomastoid muscle are incised. The sternal head of the sternocleidomastoid muscle is retracted medially and the common carotid artery exposed and encircled with umbilical tape. (Fig. 6a.) The scalenus anticus muscle is transected after isolating the overlying phrenic nerve. The subclavian artery is exposed, dissected free, and encircled with heavy silk ligatures. (Fig. 6b.) Pressures are measured in the common carotid artery and the subclavian artery to demonstrate the gradient. (Fig. 6c.) The common carotid artery is clamped and incised and a polyethylene internal shunt inserted for continuous cerebral perfusion during suturing of the graft. (Fig. 6d, e, and f.) An 8 mm. knitted Dacron graft is sutured end to side to the common carotid artery using No. 4-O polyethylene* suture material. The graft is preclotted, the internal shunt removed, sutures *Manufactured by Davis & Geck Co., Danbury,
Connecticut.
American Journal of Surgery
Occlusive
Arterial
tied, and the graft cross-clamped just beyond the anastomosis. (Fig. 6g, h, and i.) The subclavian artery is clamped proximally and distally and is incised, and the Dacron graft anastomosed end to side using similar suture material. Prior to completing the distal anastomosis, adequate flushing is accomplished to assure evacuation of any clots. (Fig. Sj and k.) Upon completing the bypass, pressure measurements are again recorded to demonstrate elimination of the gradient. (Fig. 61.) The bypass graft may be brought over, as illustrated in Figure 6, or beneath the internal jugular vein depending on the anatomic variations in the neck. The wound is closed in layers. An autogenous vein may be used for the bypass graft as was done in five cases in this series. COMMENTS
The underlying pathologic lesion in all cases was an obstructing atheromatous plaque; however a congenital cause has been reported in other cases [5,6]. The affected artery was either occluded as illustrated in Figure 2 or stenosed as illustrated in Figure 3. The result was a reduction of blood flow accounting for the symptoms of cerebrovascular insufficiency, upper extremity claudication, or combinations of these symptoms. As anticipated, when the carotid artery was involved, the symptoms were primarily those of anterior cerebral ischemia. When the obstructing lesion was in the subclavian artery proximal to the origin of the vertebral artery, symptoms were variable depending on the changes in blood flow which occurred [5]. A decrease in vertebral artery perfusion may result in a blood flow deficit to the vertebrobasilar circulation. The severity of this depends on the adequacy of the opposite vertebral artery to cross fill through the basilar artery communication. A true reversal of flow in the vertebral artery may occur so that blood is siphoned from the brain down the vertebral artery into the subclavian artery as first described by Contorni in 1960 [7]. This phenomenon is known as the subclavian steal syndrome [8,Y] or brachialbasilar insufficiency syndrome [IO]. Symptoms in these patients were often precipitated or aggravated by upper extremity movement when demand for blood in the arm and shoulder regions was sufficient to lower flow through the basilar artery below a critical level. In cases of obstruction of the proximal subclavian artery, blood is not always siphoned Vol. 114, November
1967
Disease
from the contralateral vertebral artery through the basilar artery as was illustrated in Figure 2. A “steal” of blood may occur from the carotid artery system as illustrated in Figure 7 in which contrast material injected into the left common carotid artery fills the left vertebral and subclavian arteries through branches of the external carotid artery. In cases of proximal occlusion or stenosis of the innominate artery, the carotid-subclavian bypass is not applicable and a bypass graft from the ascending aorta to the right subclavian and carotid arteries is employed. The establishment of a bypass between the carotid and subclavian arteries raises the possibility of creating a carotid “steal,” thereby producing carotid insufficiency. There has been no clinical evidence of such a phenomenon in any of our patients. The effectiveness of the bypass graft between the carotid and subclavian arteries is demonstrated by the high percentage of favorable results in this group. The importance of associated occlusive lesions of the carotid and vertebral arteries should be emphasized since correction of these disease processes combined with the bypass procedure further enhances the opportunity for remission of symptoms [ll]. Complete angiographic studies are required to delineate the site or sites of the arterial occlusive lesions. SUMMARY
Carotid-subclavian bypass has been employed in the treatment of cerebrovascular insufficiency, upper extremity claudication, or a combination of these syndromes in 125 patients. All patients were studied angiographically prior to operation with either bilateral carotid and subclavian puncture or retrograde aortic arch injection. Indications for carotid subclavian bypass operation included : upper extremity claudication, twenty-one cases; symptoms of vertebrobasilar insufficiency, forty-nine cases; upper extremity claudication combined with symptoms of vertebrobasilar insufficiency, subclavian steal syndrome, and brachial-basilar insufficiency syndrome, thirty cases; symptoms of cerebrovascular insufficiency due to an obstructing lesion at the origin of the carotid arteries, twentyfive cases. Left carotid-subclavian bypass was employed in ninety-one patients (72 per cent) and right
808
Diethrich
carotid .subclavian bypass in twenty (10 per cent). In fourteen patients (11 per cent) thromboendarterectomy of the common carotid bifurcation accompanied the carotid-subclavian bypass. There’was an operative mortality of 4.8 per cent in this series of 125 patients. Follow-up studies obtained on all patients extending from nine months to fourteen years have dcmonstrated the effectiveness of this method of operative treatment. REFERENCES
et al. 4. DE BAKEY, M. E.. DIE,L‘IIRIC~, E. V., GARRETT, H. E., and MCCUTCHEN. J. J. Surgical treatment of cerebrovascular disease. Postpzd. Med., in
press. 5. MASSUMI, R. A. Tile congenital
6.
7. 8.
1. CRAWFORD, E. S., DE BAKEY, M. E., MORRIS, G. C., JR., and COOLEY, D. A. Thrombo-oblitera-
tive disease of the great vessels arising from the aortic arch. _I. Thhoracrc6 Cardiavasc. Surg., 43: 38, 1962.
2. KILLEN, D. A., FOSTER, J. H., GOBBEL, W. G., STEPHENSON, S. E., JR., COLLINS, G. A., BIL-
LINGS, F. T., and SCOTT, H. W., JR. The subclavian steal syndrome. J. Thora& & Cardiovax. ,%7x., 51: 539, 1966. 3. DE BAKEY, M. E. Concepts UnderIying Surgical Treatment of Cerebrovascular Insufficiency. In : Clinical Neurosurgery, chapt. 17, p. 310. Baltimore, 1964. Williams & Wilkins Co.
9. 10.
11.
variety of the “subclavian steal” syndrome. Circulalion, 28: 1149, 1963. LEVINE, S., SERFAS, L. S., and KUSINK~. A. Right aortic arch with subclavian steal syndrome (atresia of left common carotid and left subclavian arteries). Am. J. Surg., 111: 632, 1966. CONTORNI, L. 11 circolo collaterale vertebrovertebrale nella obliterazione dell’arterial succlavia alla sue origine. Minerva chir., 15: 268, 1960. REIVICH, M., HOLLING, H. E., ROBERTS, B., and TOOLE, J. F. Reversal of blood flow through vertebral artery and its cffcct on crrebral circulation. New England J. Med., 265: 878, 1961. Editorial. A new vascular syntlrou~e: “The subclavian steal.” Nerc England J. Med., 265: 912, 1961. NORTH, R. R., FIELDS, W. S., DE BAKEY, M. E., and CRAWFORD, E. S. Brachial-basilar insufliciency syndrome. Nez~rdogy, 12: 810, 1962. CRAWFORD, E. S., DE BAKEY, M. E., BLAISDELL, F. W., MORRIS, G. C., JR., and FIELDS, W. S.
Hemodynamic alterations in patients with cerebral arterial insuff%ency bvfore and after operation. Szlrgery,48: iii, 1960.
Correction In the article, “A Study of Disposable Surgical Masks,” by Drs. Paul 0. Madsen and Renate E. Madsen, which appeared on page 431 of the September issue of the Journal, the trade name given far the cellulose fiber paper mask as well as the manufacturer of this product were incorrectly designated as the Paper Mask manufactured by C. R. Bard, Inc., Murray Hill, New Jersey. The correct trade name for this product is the Reitex paper mask manufactured by Edward Reitano Inc., Mt. Vernon, New York.