Transthoracic Revascularization for Brachiocephalic Occlusive Disease

Abstract

Brachiocephalic occlusive disease is an uncommon but serious problem, particularly for patients with multiple vessels involved who require transthoracic reconstruction. From 1983 to 1990, the authors treated 10 such patients, who had complex stenotic and occlusive lesions and required transthoracic reconstruction of multiple brachiocephalic arteries. Five patients had symptoms of hemispheric transient ischemic attacks, 4 had upper extremity ischemic symptoms, and 3 had prior cerebrovascular accidents. All patients had complex chronic occlusive lesions that precluded extraanatomic recon struction in the neck. The ascending aorta was the proximal anastomotic site in all cases. Bypass grafting to two or more distal sites was performed in 3 patients and to a single site in 7 patients. An additional carotid thromboendarterectomy was performed in 4 patients. One patient suffered an irreversible hemispheric infarction on the third postoperative day due to carotid artery thrombosis ipsilateral to the aortoinnominate bypass graft, for a perioperative stroke rate of 10%. Only 1 patient was found to have a graft occlusion four years postoperatively. Thus the graft patency rate was 90%. All 10 patients are alive postoperatively with a mean follow-up of seventy-two months. This direct approach to revascularization is an acceptable, durable alternative for those patients with lesions precluding standard extraanatomic reconstruction, but it is associated with an occasional perioperative stroke.