Innominate artery occlusive disease: management with central reconstructive techniques

The purpose of this study was to review our experience with central vascular reconstruction for innominate artery occlusive disease. Eighteen patients underwent central reconstruction for innominate artery (IA) occlusive disease during an 8-year period (1986 to 1994). Mean age was 59 years (range, 36 to 77 years). Women outnumbered men 12 to 6. All patients had symptoms including amaurosis fugax 55%, transient ischemic attacks 44%, vertebrobasilar insufficiency 44%, and arm claudication 33%. The IA was occluded in three patients and stenotic in 15. Three patients underwent previous extrathoracic bypass procedures for IA lesions that failed.

Operations performed through a median sternotomy included aortocarotid bypass with reimplantation of the subclavian (n = 10) and aortoinnominate bypass (n = 7). Transection and oversewing of the IA was performed in all but one patient, in whom ligation of the IA was performed. One patient with severe chronic obstructive pulmonary disease and previous coronary artery bypass grafting underwent retrograde-transluminal IA angioplasty with endovascular stent placement via a carotid approach. Four patients underwent concomitant carotid endarterectomy). Two patients underwent concomitant coronary artery bypass grafting at the time of IA reconstruction.

There was one operative death from myocardial infarction. Perioperative morbidity included dysrrhythmia (three), respiratory insufficiency (three), subendocardial myocardial infarction (two), cerebrovascular accident with complete recovery (two), hemorrhage (one), and acute graft occlusion (one). All grafts remained patient at a mean follow-up of 21 months (range, 8 to 60 months). The only patient who underwent ligation of the IA required a subsequent revision of the IA to transection and oversewing for an embolic event at 4 months status-post aortocarotid bypass. The patient who underwent angioplasty remained asymptomatic with a patient IA at 12 months. Average length of stay for transthoracic repair was 14 days and for transluminal angioplasty 2 days.

Innominate artery bypass based on the ascending aorta is effective in providing relief of symptoms and has a high patency rate. Because of the significant morbidity, these procedures should be reserved for patients with symptoms. The IA should be transected and oversewn to prevent recurrent embolism. Transcarotid, retrograde angioplasty provides an alternative approach to stenotic lesions located in the IA or proximal common carotid artery. An aggressive approach directed at defining coronary artery disease is an invaluable adjunct to the proper treatment of this patient population.