Carotid brachial bypass for treating proximal upper-extremity arterial occlusive disease

Symptomatic occlusive disease of the subclavian arteries, not associated with thoracic outlet syndrome, is an uncommon problem with a paucity of literature related to the appropriateness of bypass graft selection and long-term patency for revascularization. Between 1985 and 1993, 9 patients (3 men and 6 women) underwent 13 carotid brachial bypasses for chronic severe upper-extremity ischemia. Ages ranged from 47 to 75 years (mean 65). Three patients had documented collagen vascular disease, 1 had radiation arteritis, and 4 had bilateral disease requiring staged arterial reconstruction. Indications for operation included severe exercise-induced ischemia in two limbs (15%), rest pain in eight (62%), and gangrene or infection, or both, in three (23%). Two bypasses were performed for failed prior reconstructions. Inflow originated from the carotid artery (4 proximal and 9 bifurcation), and distal anastomoses were made to a disease-free section of brachial artery. Reinforced 6 mm thin-wall polytetrafluoroethylene (PTFE) grafts were used in all operations. No operative mortality or major upper-extremity amputation was associated with the procedure, although digital amputations were performed in four instances. Follow-up ranged from 4 to 83 months with a mean of 38 months. The 5-year primary patency rate, by life-table analysis, was 92%. Our results showed excellent long-term patency when prosthetic grafts were used for carotid brachial bypass, because of excellent runoff and the relatively short graft length required.