Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades
Thomas J Takach1, J Michael Duncan, James J Livesay
1Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX 77225-0345, USA.
Insights
Carotid-subclavian bypass (CSB) offers excellent long-term graft patency and symptom relief for brachiocephalic disease. Despite CSB
Area of Science:
- Vascular Surgery
- Cardiovascular Research
- Surgical Outcomes
Background:
- Carotid-subclavian bypass (CSB) is a critical procedure for brachiocephalic reconstruction.
- Understanding its contemporary impact and indications is vital for surgical decision-making.
Observation:
- A study analyzed 287 patients undergoing CSB for symptomatic brachiocephalic disease.
- Data included operative outcomes, long-term graft patency, and disease impact.
Findings:
- CSB demonstrated technical success in all patients with low operative mortality (1.0%) and stroke rate (2.1%).
- 15-year primary patency rates were high (86.5 ± 3.8%), with excellent freedom from restenosis (86.5 ± 3.8%) and stroke (85.6 ± 4.9%).
Implications:
- CSB provides durable symptom relief and excellent long-term outcomes.
- The underlying disease significantly impacts long-term prognosis, influencing management decisions.
- CSB offers benefits including potential survival advantage and limb function preservation.
Background:
The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction.
Methods:
We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease.
Results:
Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%.
Conclusions:
CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.
