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Surgery Risty et al 395 Volume 142, Number 3 Table II. The risk of postoperative stroke in patients with or without concomitant carotid endarterectomy Concomitant CEA N 8 No CEA N 28 CEA, carotid endarterectomy. Perioperative stroke No perioperative stroke 2 6 0 28 Average length of follow-up was based on the number of months from operation to most recent clinic visit. Follow-up ranged from 1to 212 months (mean, 66 months). Symptom resolution was determined by history and physical exam. One patient was lost to follow-up. All remaining patients (97%) had relief of symptoms. Twenty-five percent (2/8) of patients who underwent concomitant CEA sustained post-operative stroke, 1each with CST and CSB (Table II). No patients who underwent CSB or CST alone had a post-operative stroke. The risk of postoperative stroke in patients with concomitant CEA was significantly higher than the risk of stroke after CSB or CST alone (P .044). Twelve studies from the English language literature since 1990 had sufficient information to compare the rate of perioperative stroke in patients undergoing CST or CSB alone versus those who had concomitant CEA with CST or CSB (Table III). 11-22 There were only 2(0.34%) strokes in 589 patients undergoing CSB or CST alone versus 5 (3.57%) strokes in 140 patients who had concomitant CEA with CST or CSB. This difference was significant (P .004). Adding our patients to these totals, there were 2 (0.32%) perioperative strokes in 617 patients undergoing CSB or CST alone versus 7(4.73%) perioperative strokes in 148 patients who had concomitant CEA with CSB or CST. This difference was significant (P .001). DISCUSSION Both CST and CSB can be performed with relatively low rates of mortality and morbidity. There were two deaths within 30 days in our series, one after CSB and one after CST. The perioperative mortality rate following these two procedures reported in the literature has ranged from nil to 12%. 7,8,12,14,15,23-27 Edwards and associates reported 2.2% overall mortality rate after 190 extrathoracic reconstructions, including 178 CST. 14 Vitti et al. 15 reported one death after 124 P .044 Table III. Results of English-language literature review comparing the rates of perioperative stroke after CSB or CST alone or with concomitant CEA Reference Year CSB/CST alone CSB/CST with CEA Defraigne 11 1990 0/24 1/5 Perler 12 1990 1/27 0/4 Mingoli 13 1992 0/26 1/23 Edwards 14 1994 0/177 2/10 Vitti 15 1994 0/92 0/32 Salam 16 1994 0/30 0/4 vanderVliet 17 1995 0/35 0/7 Schardey 18 1996 0/93 0/15 Deriu 19 1998 0/30 1/10 Toursarkissian 20 1998 1/16 0/6 Wittwer 21 1998 0/28 0/12 Cina 22 2002 0/11 0/12 Total 2/589 (0.34%) 5/140 (3.57%) P .004 CSB procedures. Sandmann and coworkers 27 documented a1.4% mortality rate in 72 patients who underwent CST. Procedure-related complications can be grouped into several categories. Thoracic duct leaks requiring reoperation have been described by many investigators. 7,14-17,21,22,27 The incidence of thoracic duct leak can be reduced by meticulous identification and ligation of the main duct and any small lymph channels with permanent suture. Phrenic nerve injury has been reported by many groups. 12,15-17,23,24,26 These injuries appear more frequently after CSB than CST. Transient and permanent Horner’s syndrome are not infrequent following both CSB and CST. 14,17,25,26 Recurrent laryngeal nerve dysfunction has also been described. 12,14,15,17,26 Long-term results after both CSB and CST were excellent in our series. At average follow-up of more than 5years, 97% of patients had relief of symptoms. There was only 1patient in our series who required thrombectomy for graft thrombosis and there were no late operations for restenosis. Many previous studies have documented impressive long-term patency rates after CSB and CST. AbuRahma and coworkers 23 reported 92% primary and 95% secondary patency rates at 10 years. Edwards et al. 14 discovered only one failure at 26 months after 178 CST procedures. Owens and associates 24 calculated a 96.5% patency rate at a mean follow-up of 26 months after CSB. Sandmann et al. 27 reported 95% patency rates after both CSB and CST. Cina et al. 22 studied 23 patients by ultrasound at amean of 25 months after CST; all recon- Gundersen Lutheran Medical Journal • Volume 5, Number 1, July 2008 31
396 Risty et al Surgery September 2007 structions were patent. Furthermore, in aliterature review they found patency rates of 84% and 98%, respectively, in 516 patients after CSB and 511 patients after CST. This difference was significant. At a mean follow-up of 59 months, the rates of freedom from symptoms in these two groups were 88% and 99%, respectively. In our series, there were no differences in the immediate or long-term results of CST versus CSB. There was one death in each group. Although procedure-related complications such as thoracic duct leak, phrenic nerve injury, and graft thrombosis occurred only in CSB patients, the difference was not significant. The long-term results of both procedures in the relief of presenting symptoms were excellent. However, CST offers several advantages over CSB. CST is performed with asingle anastomosis, does not require aprosthetic graft, and effectively removes the stenotic lesion from arterial flow so that it cannot serve as asource of atheromatous emboli. 14,26,27 Although Sterpetti and associates 26 noted shorter operative times with CST versus CSB, we did not find asimilar trend. Although several authors quote superior long-term patency in CST patients, they caution that patients undergoing CST and CSB may not be comparable. 14 Finally, the ability to perform CST with dissection limited to the area medial to the anterior scalene muscle puts the phrenic nerve and brachial plexus at less risk of inadvertent injury. For these reasons, CST is the procedure of choice at our institution for subclavian artery lesions treated surgically. We prefer CSB for patients with multifocal subclavian stenoses, more distal subclavian stenoses, or when reoperation is necessary. Percutaneous angioplasty and stenting is also being performed with increasing frequency at our institution. Arteriosclerotic lesions develop in multiple arteries simultaneously. Concurrent stenoses in the subclavian artery and ipsilateral carotid artery bifurcation are therefore not infrequent. Defraigne and associates 11 stressed the importance of treating the carotid stenosis at the time of CSB in order to prevent acarotid steal phenomenon. Mingoli and coworkers 13 recommended acombined approach of CSB or CST with concomitant CEA for correction of subclavian and ipsilateral carotid lesions in order to avoid the development of symptoms from each respective stenosis. They reasoned that significant carotid stenoses left untreated would cause neurologic deficits during follow-up. Edwards and coauthors 14 also performed concomitant CEA in 10 of 178 patients undergoing CST. The only 2perioperative strokes in their series occurred in patients who also had CEA. We found the risk of perioperative stroke to be significantly higher in patients after concomitant CEA with CSB or CST. A collected review of current literature corroborated this finding. Adding our experience to the collected review totals, perioperative stroke occurred in only 2(0.32%) of 617 patients after CSB or CST alone versus 7(4.73%) of 148 patients with concomitant CEA (P .001). The low risk of stroke after CST or CSB alone has been attributed to several factors. Edwards et al. 14 have stressed the importance of collateral circulation through the external carotid arteries while the anastomosis is being performed at the proximal common carotid artery. Furthermore, the common carotid artery at this level is usually free of atheromatous plaque at the site of clamp placement, decreasing the risk of embolization. The marked increase in the risk of stroke after combined CEA and CSB or CST can be contrasted to the risk of perioperative stroke after CEA alone for asymptomatic, severe carotid stenoses. The disabling stroke rates reported in the ACAS and ACST studies were 1.4% and 0.7%, respectively. 28,29 At our institution over the last 10 years, the perioperative stroke rate after CEA for asymptomatic stenoses was 0.9%. 30 It is unclear why the addition of CEA to CSB or CST is associated with such asignificant increase in the risk of perioperative stroke. Although the increased stroke rate may be areflection of more severe vascular disease involving two arterial beds, the additive risks of two procedures should also be considered. This finding parallels the results of combined CEA and CABG for simultaneous carotid and coronary artery stenoses. Arecent meta-analysis of concomitant CEA with CABG concluded that the risk of stroke was dramatically higher compared with CEA and CABG performed in astaged fashion. 31 Coyle and associates 32 reported 18.2% 30-day risk of stroke or death after simultaneous CEA and CABG versus 6.6% when the procedures were done separately. Reasons proposed for the marked increase in stroke risk include the effects of multiple arterial clamping sites, prolonged operative times, and inadequate anticoagulation. Each of these factors may play arole in combined CEA and CSB or CST procedures. We agree that severe ipsilateral internal carotid artery stenoses should be aggressively treated for best stroke prevention and to prevent the rare case of carotid steal. However, based upon our experience herein along with results of contemporary literature review, we cannot support concomitant CEA at the time of CSB or CST due to asignificantly greater risk of perioperative stroke when compared with CSB or CST alone. We have changed our approach to 32 Gundersen Lutheran Medical Journal • Volume 5, Number 1, July 2008
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