Subclavian and Innominate Revascularization: Surgical Therapy Versus Catheter-Based Intervention

Proximal subclavian or brachiocephalic artery obstruction may present with a variety of symptoms. Surgery has been considered by many to be the corrective procedure of choice, but percutaneous alternatives are becoming increasingly popular. Little work has been done to compare the outcomes of the two techniques. Presenting symptoms in this condition often include angina secondary to coronary-subclavian steal, subclavian steal syndrome, arm ischemia, and axillo-femoral graft inflow obstruction. A systematic review of the surgical literature has been performed and has included analysis of the incidence of technical success, overall complications, stroke, death, and subsequent patency. However, despite comparison of these data to the published series of stenting, there are no head-to-head trials of one technique versus another. Review and analysis of the contemporary literature suggests a high patency and low complications in stent series, and is in contrast to similar midterm patency but a higher incidence of stroke and death in the surgical literature. A variety of techniques can be used for successful stent-based revascularization, and a blending of skills from the traditional "coronary" and "peripheral" venues may be helpful. Comparison with the published surgical experience suggests that the effectiveness of percutaneous revascularization is at least equivalent and that these techniques may be associated with fewer procedure-related serious complications. Percutaneous stenting should be considered a first-line therapy in treating subclavian or brachiocephalic obstruction.