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Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery
A F AbuRahma1, P A Robinson, M Z Khan
1Department of Surgery, West Virginia University Health Sciences Center, Charleston Area Medical Center.
Insights
Carotid-subclavian bypass (CSBP) offers superior long-term graft patency compared to axilloaxillary artery bypass for treating upper extremity ischemia and transient ischemic attacks. CSBP is recommended as the primary surgical option.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Arterial Bypass Procedures
Background:
- Upper extremity ischemia and cerebrovascular events necessitate surgical intervention.
- Carotid-subclavian bypass (CSBP) and axilloaxillary artery bypass are surgical options.
- Polytetrafluoroethylene grafts are commonly used in these bypass procedures.
Purpose of the Study:
- To compare the long-term outcomes of carotid-subclavian bypass (CSBP) and axilloaxillary artery bypass.
- To evaluate graft patency, complication rates, and symptom recurrence for both procedures.
- To determine the preferred surgical approach for specific vascular conditions.
Main Methods:
- A retrospective study of 67 patients undergoing CSBP or axilloaxillary artery bypass.
- Follow-up for a mean of approximately 70 months.
- Graft patency assessed via clinical evaluation, Doppler pressures, duplex ultrasonography, and angiography.
Main Results:
- Both procedures had similar 30-day mortality (approx. 3%) and complication rates.
- 100% initial symptom relief in both groups, but higher recurrence in axilloaxillary bypass (20% vs. 5.6%).
- CSBP demonstrated significantly higher 10-year primary (93.8% vs. 66%) and secondary (93.8% vs. 84.6%) patency rates.
Conclusions:
- CSBP and axilloaxillary artery bypass have comparable short-term morbidity and mortality.
- CSBP exhibits superior long-term graft patency, making it the preferred procedure.
- Axilloaxillary artery bypass should be reserved for high-risk patients unsuitable for CSBP.
Abstract:
Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.