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Common brachiocephalic trunk: strategies for revascularization
A Azakie1, D B McElhinney, L M Messina
1Division of Vascular Surgery, University of California, San Francisco 94143-0222, USA.
Insights
Revascularization effectively treats occlusive disease of the common brachiocephalic trunk, a variant affecting 10% of people. Surgical options like bypass grafts or endarterectomy offer durable symptom relief but carry risks of neurological complications.
Area of Science:
- Vascular Surgery
- Cerebrovascular Disease
- Aortic Arch Anatomy
Background:
- Common brachiocephalic trunk (CBT) is a normal aortic arch variant in ~10% of the population.
- CBT supplies major cerebral blood flow; stenosis/occlusion causes severe ischemia.
- Limited data exists on managing occlusive CBT disease.
Purpose of the Study:
- To review management options for occlusive disease of the common brachiocephalic trunk.
- To evaluate the efficacy and durability of revascularization procedures for CBT occlusive disease.
Main Methods:
- Retrospective review of 6 patients with symptomatic CBT occlusion or stenosis (1977-1997).
- Revascularization via ascending aorta to innominate/carotid bypass (n=5) or endarterectomy (n=1).
- Underlying causes included atherosclerosis (n=5) and Takayasu's arteritis (n=1).
Main Results:
- One perioperative death (myocardial infarction) and one stroke.
- One case of cerebral hyperperfusion syndrome resolved with medication.
- Long-term follow-up (1-20 years) showed no symptomatic recurrence in survivors.
Conclusions:
- Revascularization using bypass grafts or endarterectomy provides effective symptom relief for occlusive CBT disease.
- Neurologic complications, including one fatality, highlight the risks associated with CBT occlusive disease and its treatment.
Background:
A common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is a normal variant of aortic arch branching that occurs in approximately 10% of the population. Because three of the four primary sources of cerebral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revascularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy.
Methods:
A retrospective review of our experience with innominate artery revascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997. All patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n = 3) caused by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revascularization was achieved by a prosthetic bypass graft from the ascending aorta to the innominate or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessels was performed in 3 patients.
Results:
There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital discharge. One patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy that resolved without sequelae with antihypertensive medications. During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years after operation. All surviving patients are alive and free from symptomatic recurrence.
Conclusions:
Revascularization for occlusive disease of a common brachiocephalic trunk can be achieved with effective and durable relief of symptoms using either a prosthetic bypass graft or endarterectomy. However, neurologic complications in 2 patients, which were fatal in 1, attest to the potential cerebral ischemic threat posed by occlusive disease of a common brachiocephalic trunk.
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