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Carotid-subclavian arterial reconstruction: Concomitant ipsilateral carotid endarterectomy increases risk of perioperative stroke Gina M. Risty, MD, Thomas H. Cogbill, MD, Clark A. Davis, MD, and Pamela J. Lambert, RN, BSN, La Crosse, Wisconsin Background. Carotid-subclavian bypass (CSB) and carotid-subclavian transposition (CST) have excellent long-term patency with low perioperative mortality and morbidity. Carotid endarterectomy (CEA) is necessary for severe ipsilateral internal carotid artery stenosis in asmall subset of these patients. CEA can be performed as acombined or separate procedure. This study was undertaken to delineate the results of CSB and CST at our institution and to determine if concomitant CEA with CSB or CST is safe. Methods. We evaluated the outcome of 36 patients with symptomatic subclavian artery stenosis treated surgically at asingle institution during a22-year period. Outcomes of patients undergoing CSB or CST with concomitant CEA were compared with those of patients undergoing CSB or CST alone. Available literature was reviewed to compare the rate of perioperative stroke following CSB or CST with concomitant CEA versus CSB or CST alone. Results. Twenty-one patients underwent CST and 15 patients underwent CSB. There were 2(5.6%) deaths and 2(5.6%) strokes within 30 days of surgery. Concomitant CEA was performed in 6CST patients and 2CSB patients. Both perioperative strokes occurred in patients who had concomitant CEA. There were no strokes in the CST or CSB alone group (P .044). In acollected review of 12 evaluable studies plus our experience, the rate of perioperative stroke was 0.32% in 617 patients who underwent CSB or CST alone versus 4.73% in 148 patients who had concomitant CEA with CSB or CST (P .001). Conclusions. Both CSB and CST are safe and effective for symptomatic subclavian artery stenosis, with excellent long-term results. In patients also requiring CEA, the rate of perioperative stroke is significantly higher with acombined procedure. Consideration should be given to performing CEA separately from CSB or CST. (Surgery 2007;142:393-7.) From the Department of General &Vascular Surgery, Gundersen Lutheran Medical Center, La Crosse, Wisconsin Patients presenting with symptomatic subclavian artery stenosis are uncommon. Edwards et al. 1 reported that in over 5000 patients presenting with cerebral symptoms, only 11.7% were due to astenosis of the subclavian artery, the vertebral artery, or both. Symptoms of subclavian artery stenosis most frequently include arm claudication, rest Accepted for publication March 16, 2007. Reprint requests: Thomas H. Cogbill, MD, Department of Surgery, Gundersen Lutheran, 1900 South Avenue, C05-001, La Crosse, Wisconsin 54601. E-mail: thcogbil@gundluth.org. 0039-6060/$ -see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.03.014 pain, or ischemic changes of the ipsilateral hand or digits. 2 Vertebrobasilar symptoms may also result from subclavian artery steal from the vertebral artery or embolic events in the distribution of the vertebral artery. These patients may present with dizziness, syncope, ataxia, vertigo or bilateral blurred vision 3 Less commonly, patients can present with chest pain following coronary artery bypass grafting (CABG) in which an internal mammary artery graft originates from asubclavian artery with aproximal stenosis. This may cause reversal of flow in the internal mammary artery graft to provide flow to the distal subclavian artery, resulting in coronary– subclavian steal syndrome. 4,5 Treatment of symptomatic subclavian artery stenosis has undergone significant change over the past several decades. Transthoracic endarterec- SURGERY 393 Gundersen Lutheran Medical Journal • Volume 5, Number 1, July 2008 29
394 Risty et al Surgery September 2007 tomy and bypass procedures were initially attempted but fell out of favor due to unacceptably high perioperative morbidity and mortality. 6-8 Extrathoracic bypass and transposition procedures were then developed, resulting inasignificant reduction in morbidity and mortality. Most recently, percutaneous techniques of angioplasty and stenting are increasingly being used to treat symptomatic subclavian artery stenosis. 9,10 This study was undertaken to determine the immediate and long-term results of carotid-subclavian bypass (CSB) and carotid subclavian transposition (CST) performed at our institution. In addition, we sought to determine the safety of concomitant carotid endarterectomy (CEA) in that subset of patients with severe ipsilateral carotid artery stenosis. PATIENTS AND METHODS All patients with adiagnosis of subclavian artery stenosis (ICD-9 code 435.2) treated from June 1983 to December 2005 were identified. Inpatient hospital and outpatient clinic records were then reviewed. Sixty-five patients were identified; 23 asymptomatic patients did not require any intervention and these patients were excluded from further analysis. Also excluded were 4patients who underwent endovascular subclavian artery angioplasty and stenting, and 2who underwent transthoracic aortic to brachiocephalic branch bypass procedures. Thirty-six patients included in this study underwent either CSB or CST. All procedures were performed at a single institution under general anesthesia. Twenty-eight (78%) procedures were performed by a single surgeon. Hospital charts and outpatient clinic records were retrospectively reviewed for presenting symptoms, risk factors, demographics, pre-operative studies, and operative data. Operative results, postoperative complications, and long-term follow-up were also determined. Fisher’s exact test was used to analyze the data after confirmation that all pertinent statistical assumptions were met. Level of confidence was defined at P .05. RESULTS Patients ranged in age from 46 to 83 years (mean 63.9 years). Twenty-six (72%) of the patients were women. Comorbid conditions included hypercholesterolemia in 18 (50%), hypertension in 18 (50%), coronary artery disease in 12 (33.3%), diabetes mellitus in7(19.4%), previous myocardial infarction in 3 (8.3%), renal insufficiency in 3 (8.3%), congestive heart failure in 2 (5.6%), chronic obstructive pulmonary disease in 2(5.6%), Table I. Presenting symptoms for 36 patients with subclavian artery stenosis Symptoms No. of patients Arm claudication 22 Vertebrobasilar symptoms 18 Coronary-subclavian steal 2 Asymptomatic 1 and previous cerebral vascular accident in 1 (2.8%). Thirty-one (86.1%) of patients hadasmoking history. Presenting symptoms are shown in Table I, with several patients having more than 1 presenting symptom. Of 36 patients, 21 (58.3%) underwent CST and 15 (41.7%) underwent CSB with polytetrafluoroethylene (PTFE) grafts. Eight patients underwent concomitant carotid endarterectomy (CEA); 6patients with CST and 2patients with CSB. Operative time for the CSB patients ranged from 90 to 395 minutes (mean 189 minutes). Operative time for the CST patients ranged from 80 to 335 minutes (mean 178 minutes). Length of stay ranged from 1to27 days for CSB patients (median, 5days); and 1to14 days for CST patients (median, 3days). Over the 22-year period, the average length of stay steadily decreased. There were no statistically significant differences between the 2 groups when operative times or length of stay were compared. Two of 36 patients died within 30 days of surgery for a mortality rate of 5.6%. One patient death occurred in each of the CSB and CST groups. One patient had an uncomplicated hospital course and was discharged home the day following surgery, but died at home 3days later of an unknown cause. The second patient had multiple serious medical comorbidities including end-stage renal disease, chronic obstructive pulmonary disease, hypertension and hypercholesterolemia. Postoperatively, the patient developed pneumonia, myocardial infarction and pulmonary aspiration. This patient died 14 days after surgery, with multi-system organ failure. Two patients developed thoracic duct leak following CSB. Both were managed with re-operation and closure of the leak. One patient in the CSB group sustained a phrenic nerve injury; this resolved in less than 6 months with conservative management. A patient in the CSB group who developed early graft thrombosis was managed with successful re-operation. Although there were more perioperative complications in CSB patients than CST patients, the differences were not significant. 30 Gundersen Lutheran Medical Journal • Volume 5, Number 1, July 2008
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