The management of stenotic and obstructive lesions of the aortic arch branches

The stenotic internal carotid can be managed in a variety of ways and number of tests can be utilized for assessing the collateral blood flow. Except in unusual situations, carotid thromboendarterectomy with or without a patch graft is generally employed. Although some surgeons use no protective shunt at all, or only upon specific indications, intraluminal shunting is utilized extensively. Our preference is to employ the customary Javid shunt technic except in unusual circumstances that suggest that added safety may be assured by shortening to a matter of seconds the period of interruption of carotid flow. In such cases, we believe the temporary axillary-internal carotid intraluminal shunt is of considerable value. Although mediastinal and thoracic procedures and bypass grafts delivering blood from the ascending aorta are not needed nearly as often as they were formerly, they are essential in certain cases. They yield excellent results and carry small risk. Carotid-subclavian grafts have proved quite valuable in restoring pulsatile flow to the subclavian and carotid systems. Our preference, however, because of technical simplicity, is the carotid-axillary bypass procedure. Subclavian-subclavian and axillary-axillary grafts have been employed successfully. When a carotid-axillary bypass is feasible, we would choose this method instead and reserve the others for unusual anatomic-pathologic situations.