Carotid-subclavian bypass and the carotid steal phenomenon

Twelve patients with patent carotid-subclavian bypass grafts were investigated by colour flow duplex imaging to look for a carotid steal. Centre-stream peak systolic flow velocities in the common carotid arteries distal to the take-off of the bypass graft were equivalent to those in the contralateral common carotid artery. On the side of the bypass, common carotid flow proximal to the graft was almost double that on the distal side. Steal phenomena were not identified in the carotid artery either with the arm at rest or during hyperaemia. However, in two instances arm hyperaemia caused reversal of flow in the ipsilateral vertebral artery, suggesting the induction of a subclavian steal. The method of centre-stream peak systolic velocity as an index of flow confirmed that carotid-subclavian bypass can be safely carried out without depriving the cerebral circulation of the normal carotid inflow.     

Subclavian artery revascularization: a comparison between carotid-subclavian artery bypass and subclavian-carotid transposition

Extrathoracic revascularization has become the most popular form of surgical treatment of symptomatic subclavian disease. Despite the many theoretical advantages, subclavian-carotid transposition (SCT) has not gained wide popularity. During a 15-year period, 46 patients underwent carotid-subclavian bypass (CSB) or SCT for symptoms referable to occlusion of the subclavian artery. Follow-up ranged from 2 to 148 months (mean, 46.9 months). Seven-year actuarial patency rate was 100% for SCT and 86% +/- 7% for CSB (p = NS). Mean operative time and intraoperative blood loss were significantly reduced for SCT (p less than 0.05). After CSB a continuous deterioration of the hemodynamic status of the reconstruction was noted, whereas there were no significant changes after SCT (p less than 0.05). Whenever feasible, SCT should be considered the operation of choice for patients with symptomatic severe subclavian artery disease.     

Embolic lesions from the subclavian artery causing transient vertebrobasilar insufficiency

Thirteen patients with transient vertebrobasilar insufficiency caused by emboli from a proximal subclavian artery lesion were treated over a 5-year period. This group was characterized by the absence of significant carotid disease (12 of 13 patients) and equal arm pressures bilaterally in most patients (8 of 13 patients). An isolated supraclavicular bruit (12 of 13 patients) and a history of ipsilateral digital ischemia (5 of 13 patients) were common. Arch angiography demonstrated proximal subclavian lesions in 12 patients, with obvious ulcerations in 10 cases and thrombus in an old carotid-subclavian bypass graft in one case. Surgery directed at removal or exclusion of the lesion was successful in all cases. Isolated lesions in the subclavian artery can be a source of emboli into the vertebrobasilar circulation. These lesions are effectively treated by exclusion and vascular reconstruction.     

The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass

From May 1964 to June 1983, 36 carotid-subclavian bypasses were done in 36 patients who had symptomatic lesions at the origin of the common carotid and/or subclavian arteries at the Center for Health Sciences of the University of California, Los Angeles. Ages ranged from 28 to 82 years (mean, 58 years). Eighteen bypasses were done with prosthetic grafts, 13 done with autogenous vein, and five were transpositions with primary anastomosis of the subclavian and carotid arteries. Follow-up was available on all patients and ranged from 9 to 156 months (mean, 51.5 months). The graft patency rate at 5 years determined by actuarial methods and documented by clinical examination, noninvasive evaluation, and/or arteriography was 94.1% for prosthetic grafts and 58.3% for vein grafts (p <0.01). The 5-year cerebrovascular accident (CVA) rate for patients with carotid-subclavian bypass done with prosthetic grafts was 6% in contrast to 39% for those with vein grafts (p <0.0545). All reconstructions done by transposition and primary anastomosis remain patent and there have been no late CVAs. We conclude that prosthetic grafts are the arterial substitute of choice in carotid-subclavian bypass. Transposition and primary anastomosis between the carotid and subclavian artery, when technically feasible, may be preferable to the use of free grafts in carotid-subclavian reconstruction. (J VASC SURG 1986;3:140-5.)     

Carotid to subclavian bypass and Amplatzer vascular plug subclavian endovascular occlusion before thoracic open or endovascular repair

ObjectiveThe aim of this study was to evaluate the safety and effectiveness of endovascular occlusion of the prevertebral subclavian artery (SA) using an Amplatzer vascular plug after prophylactic revascularization with carotid-subclavian bypass (CSB) in the setting of endovascular thoracic stent grafting or open arch repair with frozen elephant trunk.MethodsAll patients who underwent SA plug embolization (SAPE) and CSB from September 2009 to December 2018 were enrolled in a registered study (SAPE study: clinicaltrials.gov NCT03620006). The primary end point was technical success, defined as complete occlusion of the origin of the SA, and how it was influenced by SA anatomy. The secondary end points were access vessel complications, cerebrovascular events, and CSB patency.ResultsThe 101 SAPE procedures were performed using a type I (35 patients) or a type II (66 patients) Amplatzer vascular plug. A percutaneous ipsilateral upper extremity access was used in 66% of patients and a radial artery access was used in 50% of procedures. The 30-day primary technical success rate was 95% (five patients received an additional plug during the index); five type IC endoleaks were observed and successfully treated either with surgical ligation (in open arch repair procedures) or secondary embolization procedure (thoracic endovascular aneurysm repair group). Three access vessel complications (3%) were recorded with percutaneous brachial approach. At a median follow-up time of 11 months (range, 2-19 months), no new-onset type IC endoleak was observed, and the CSB patency rate was 97%.ConclusionsSAPE after CSB is feasible and safe, and has low incidence of type IC endoleaks. Further device developments are needed to better adapt to the subclavian anatomy.     

Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience

OBJECTIVE: The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. METHODS: The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. RESULTS: One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9. 8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 +/- 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. CONCLUSION: The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions.     

Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery bypass.

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.     

Carotid-subclavian arterial reconstruction: concomitant ipsilateral carotid endarterectomy increases risk of perioperative stroke

BACKGROUND: Carotid-subclavian bypass (CSB) and carotid-subclavian transposition (CST) have excellent long-term patency with low perioperative mortality and morbidity. Carotid endarterectomy (CEA) is necessary for severe ipsilateral internal carotid artery stenosis in a small subset of these patients. CEA can be performed as a combined or separate procedure. This study was undertaken to delineate the results of CSB and CST at our institution and to determine if concomitant CEA with CSB or CST is safe. METHODS: We evaluated the outcome of 36 patients with symptomatic subclavian artery stenosis treated surgically at a single institution during a 22-year period. Outcomes of patients undergoing CSB or CST with concomitant CEA were compared with those of patients undergoing CSB or CST alone. Available literature was reviewed to compare the rate of perioperative stroke following CSB or CST with concomitant CEA versus CSB or CST alone. RESULTS: Twenty-one patients underwent CST and 15 patients underwent CSB. There were 2 (5.6%) deaths and 2 (5.6%) strokes within 30 days of surgery. Concomitant CEA was performed in 6 CST patients and 2 CSB patients. Both perioperative strokes occurred in patients who had concomitant CEA. There were no strokes in the CST or CSB alone group (P = .044). In a collected review of 12 evaluable studies plus our experience, the rate of perioperative stroke was 0.32% in 617 patients who underwent CSB or CST alone versus 4.73% in 148 patients who had concomitant CEA with CSB or CST (P < .001). CONCLUSIONS: Both CSB and CST are safe and effective for symptomatic subclavian artery stenosis, with excellent long-term results. In patients also requiring CEA, the rate of perioperative stroke is significantly higher with a combined procedure. Consideration should be given to performing CEA separately from CSB or CST.     

Axillo-axillary bypass with polytetrafluoroethylene graft for coronary subclavian steal syndrome

The purpose of this study is to report the results of axillo-axillary bypass (AAB) for coronary subclavian steal syndrome due to proximal subclavian artery occlusion. From 2003 to 2010, AAB using a polytetrafluoroethylene (PTFE) graft was performed in 11 patients with coronary subclavian steal syndrome. There was no perioperative mortality, stroke or cardiac complications. Over a mean follow-up of 36 months (range: 6-81 months), all bypass grafts have remained patent. No patient developed recurrent symptoms of myocardial ischemia. One patient died from hemorrhagic stroke at 31 months. Our results showed that AAB using a PTFE graft provides an effective and durable treatment option for coronary subclavian steal syndrome when attempted endovascular therapy of the occluded proximal subclavian artery is unsuccessful.     

Subclavian artery to external carotid artery bypass with saphenous vein graft in the treatment of common carotid artery stenosis

A case of TIAs due to proximal common carotid artery stenosis which was successfully treated with autogenous saphenous vein graft between the subclavian artery and the external carotid artery is presented. A 57-year-old, right handed female was admitted to our hospital for the treatment of left common carotid artery stenosis which was pointed out at a local hospital. She had a 7-years' history of repeated transient right hemiparesis and/or left amaurosis fugax. No neurological deficit was revealed on admission. Angiography showed an 80% irregular stenosis of the left common carotid artery at its origin, hypoplastic A1-portion of the left anterior cerebral artery and hypoplasia of the left posterior communicating artery. No other stenotic lesions were disclosed in a four-vessel study. Several kinds of surgical procedures have been reported for the treatment of common carotid stenotic lesion, in accordance with the site and extension of the lesion and hemodynamic factors. To maintain a sufficient blood flow of the left internal carotid artery, we considered four different operative methods such as (1) endarterectomy of the common carotid artery, (2) subclavian to common carotid artery bypass, (3) subclavian to external carotid artery bypass and (4) subclavian to middle cerebral artery bypass. The first two operative procedures force to clamp the common carotid artery which was the only one feeding artery of the left middle cerebral artery because of poor cross flow in this case. These procedures were thought highly possibly to give rise to cerebral infarction on the left side. The fourth method needs a long graft which has higher risk of bypass occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical Treatment of Coronary Subclavian Steal Syndrome with Carotid Subclavian Bypass

Coronary subclavian steal syndrome (CSS) results from proximal subclavian artery occlusive disease causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass leading to myocardial ischemia. Although percutaneous transluminal angioplasty and stent (PTAS) for subclavian lesions has been successful, it is not always feasible. In this study, the results of carotid subclavian bypass (CSB) for symptomatic CSS due to subclavian occlusion and stenosis not amenable to PTAS were analyzed. The records of patients undergoing CSB for CSS between 1991 and 2001 were reviewed. Patients with lesions not amenable to angioplasty or stent were selected for CSB. Degree of preoperative myocardial ischemia was stratified according to New York Heart Association classification. Graft patency was analyzed by life-table methods. Our results showed that CSB for treatment of symptomatic CSS can be performed safely with excellent mid-term durability. In the setting of proximal subclavian artery disease not amenable to PTAS, CSB provides an acceptable means of treatment for symptomatic CSS.     

Subclavian carotid transposition and bypass grafting: consecutive cohort study and systematic review

PURPOSE: We describe outcomes in a cohort of patients undergoing subclavian carotid transposition (SCT) for occlusive disease of the first segment of the subclavian artery and perform a systematic review of the literature on SCT and carotid subclavian bypass grafting (CSB). METHODS: Relevance, validity and extraction of review results were done in duplicate. Data were collected prospectively in our consecutive cohort of patients. RESULTS: From September 1990 to February 2001, we performed 27 SCTs, four for aneurysmal disease and 23 for occlusive disease. SCTs done for aneurysms were excluded from the current analysis. In patients with occlusive disease, the primary indications for surgery were vertebrobasilar and carotid symptoms (10, 44%), vertebrobasilar insufficiency (7, 30%), vertebrobasilar and arm symptoms (4, 17%), carotid symptoms (1, 4%), and vertebrobasilar, carotid, and arm symptoms (1, 4%). An SCT was performed in conjunction with an endarterectomy of the carotid artery in 12 patients (52%), with an endarterectomy of the subclavian artery in seven patients (30%), and with an endarterectomy of the vertebral artery in six patients (26%). A lymph leak complicated two surgeries (9%). In our series, patients improved clinically after surgery, and reconstructions were all found to be patent by means of Doppler ultrasound scanning at a mean follow-up of 25 +/- 21 months. Three patients (13%) died during follow-up of complications of coronary artery disease. From 1966 to 2000, 516 patients who underwent CSB and 511 patients who underwent a SCT were reported in the literature. Patency rates were 84% and 98%, respectively (P <.0001; absolute risk reduction, 15%; number-needed-to-treat-differently, 7), and the rates of freedom from symptoms were 88% and 99%, respectively, at a mean follow-up of 59 +/- 17 months (range, 1-228 months). CONCLUSION: Our cohort study showed that SCT is safe and effective for reconstruction of the first segment of the subclavian artery. The systematic review suggested that rates of patency and freedom from clinical symptoms are higher with SCT than with CSB.     

Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.     

Axilloaxillary bypass: is it worthwhile?

To evaluate the efficacy and long-term patency results of axilloaxillary bypass, a review of 32 patients with follow-up extending to 11 years was done. Twenty-two bypasses were performed for vertebrobasilar symptoms or subclavian steal and 10 for upper extremity claudication and/or ischemia. The mean age of the operative group was 66 years, 94% of patients had more than one atherosclerotic risk factor (hypertension, diabetes, coronary artery disease, smoking), and 75% had undergone a previous arterial reconstruction operation. There were no operative deaths, and the only postoperative complication was a sterile seroma which responded to aspiration. At late follow-up extending to 11 years, three grafts had thrombosed while another became infected and had to be removed; no limb loss resulted from these graft failures and the actual late patency rate was 87%. Carotid-subclavian bypass, intrathoracic bypasses, and endarterectomy at the site of occlusion have all been suggested for the treatment of symptomatic proximal subclavian artery disease. With axilloaxillary bypass, however, the hazards associated with carotid artery manipulation, operation on the notoriously treacherous subclavian artery, and the morbidity related to thoracotomy in this older, high-risk patient population can be avoided. The axilloaxillary bypass is safe and simple, and the excellent long-term patency rates make it the procedure of choice for symptomatic subclavian artery disease.     

Subclavian artery reconstruction in patients undergoing coronary artery bypass grafting.

The presence of occlusive disease of the subclavian artery (SCA) proximal to the origin of the internal thoracic artery (ITA) influences the operative strategy and the outcome of coronary artery bypass grafting (CABG). Of 780 patients who underwent CABG, concomitant SCA occlusive lesions were reconstructed in 13 patients (nine males, four females). The affected SCAs were left-sided in 11 patients, and right-sided and bilateral in one, each. An aortoaxillary bypass utilizing an 8-mm PTFE graft was constructed in nine patients and a carotid-subclavian (C-S) transposition in two, simultaneously with CABG. Percutaneous balloon angioplasty with a stent was performed in two patients prior to CABG. With follow-up periods ranging from 4 to 8.4 years (mean, 6.3 years), aortoaxillary bypass grafts were patent in all patients. Other reconstructive procedures, including a C-S transposition and balloon angioplasty, were performed safely and effectively in off-pump CABG patients. In six patients, the left internal thoracic artery (LITA) could be used as a graft to the coronary artery after SCA reconstruction. Aortoaxillary bypass using an 8-mm PTFE graft is a safe and effective way for simultaneous subclavian reconstruction in patients undergoing CABG. Mid-term patency of the graft is satisfactory. The LITA can be used as a graft to the coronary arteries in selected patients. Preoperative brachial angiography is mandatory in these patients.     

Result of bypass grafting for upper limb ischemia

Bypass grafting in the treatment of upper extremity ischemia is required far less frequently than it is in the lower extremity. The present study was undertaken to evaluate functional results and long-term patency of such grafts. Between 1978 and 1984, 33 bypass grafts were performed to relieve hand and forearm ischemia in 27 patients. The indication for bypass was neglected trauma (violent or iatrogenic) in 12 cases, primary arteriopathy in nine patients, and vascular complications of thoracic outlet compression in six patients. A reversed saphenous vein graft was used in 22 cases, and polytetrafluoroethylene was used in the remaining 11 procedures. Proximal anastomoses were from the aortic arch (one), subclavian artery (five), axillary artery (11), carotid artery (seven), and brachial artery (nine). Distal reconstructions were to the subclavian (three), axillary (three), brachial (16), radial (four), ulnar (two), and interosseous (five) arteries. Complete pre- and postoperative Doppler pressure measurements were available in 19 cases and demonstrated a significant increase in forearm systemic pressure index, from 0.51 before bypass to 0.86 postoperatively (p less than 0.001). Finger systolic pressure measurement in 10 patients also showed a significant improvement after operation. Follow-up of 31 grafts from 6 to 72 months (mean, 35.5 months) revealed an overall patency rate of 73% at 2 years and 67% at 3 years. Similar to lower extremity revascularization, more proximal grafts fared better; the 2-year patency rate was 83% for grafts at or above the brachial artery but only 53% for bypass distal to the brachial bifurcation. Major amputation was not required in any case, even after graft occlusion.     

Effect of blood flow rate and donor vessel diameter on the patency of carotid venous bypass grafts in dogs

A saphenous vein graft was implanted from the right subclavian to the right common carotid artery in seven dogs (group I) and between the right and left common carotid arteries in another seven dogs (group II). The recipient artery was ligated proximally to augment blood flow through the graft. Immediately after the anastomoses were completed, the average blood flow through the graft was 32 +/- 25 mL/min in group I and 122 +/- 22 mL/min in group II. At sacrifice 30 days later, angiography showed that all grafts in group I were thrombosed, whereas six (87.5%) of seven grafts in group II were patent. These findings suggest that a larger donor vessel diameter and higher graft flow rates may improve patency in venous bypass grafts that are 3 to 5 mm in diameter.     

Combined subclavian-external carotid and superficial temporal-middle cerebral artery bypass graft

A variation of a superficial temporal-middle cerebral artery bypass is presented that can serve as a surgical alternative to long vein subclavian-middle cerebral artery grafting in patients with common carotid artery occlusion and symptoms of ipsilateral ischemia. A vein graft from the subclavian to the external carotid artery at the carotid bifurcation is performed simultaneously with a standard superficial temporal-middle cerebral artery bypass. Advantages of this procedure over a long subclavian-middle cerebral artery vein graft are the technical simplicity associated with a standard superficial temporal-middle cerebral artery bypass, higher patency rates, and lower risk of graft leakage or torsion. Three patients have undergone this procedure, and all had patent bypasses one year after operation.     

A twelve-year experience with the popliteal-to-distal artery bypass: the significance and management of proximal disease.

The value of the popliteal-to-distal artery bypass in limb salvage is well documented. However, the influence of progression of disease in the superficial femoral artery or proximal popliteal artery, and the role of percutaneous transluminal angioplasty of these vessels before bypass have not been adequately assessed. To evaluate these and other factors, we reviewed our experience with 153 nonsequential popliteal-to-distal artery bypasses performed over a 12-year period. Limb salvage was the indication for all procedures, and 87% of the patients were diabetic. The 5-year primary and secondary graft patency rates were 55% and 60%, respectively, and the limb salvage rate was 73%. Preoperative arteriograms were evaluated for stenosis in the superficial femoral artery or popliteal artery proximal to the graft. Fifty-six grafts with a proximal stenosis 20% or less were identified and had primary graft patency of 77% at 2 years, similar to the 70% patency for the 20 grafts placed distal to a 21% to 35% stenosis. The 18 grafts placed distal to a stenosis greater than 35% had 53% 2-year primary graft patency (p = 0.25). Percutaneous transluminal angioplasty of a superficial femoral artery or popliteal artery stenosis (24% to 85% luminal narrowing) in 19 limbs resulted in 68% 2-year graft patency, not significantly lower than grafts with 35% or less proximal stenosis (75%, p = 0.25). Other factors associated with significant decreases in graft patency included a vein graft diameter less than 3.0 mm, a dorsalis pedis outflow site, and poor quality outflow. Thus the popliteal-to-distal bypass is a durable procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Durability of autogenous vein and polytetrafluoroethylene bypass grafts to the carotid arteries

BACKGROUND: Bypass for extra-cranial arterial disease is infrequently carried out. We reviewed our experience to determine the outcome of carotid artery grafting using either an autogenous vein or polytetrafluoroethylene (PTFE). METHODS: Details of patients were recorded prospectively as part of a vascular surgical registry. Patients identified from the registry as having carotid artery bypass procedures were classified according to the type of conduit used. Comparison was made between patients with autogenous vein and PTFE grafts. RESULTS: Between 1978 and 2002, 24 patients (13 men and 11 women) mean age 60.0 +/- 13.4 years (range, 20-81 years) underwent 28 bypass procedures (three were bilateral and one was a reoperation). Symptomatic carotid disease was the clinical indication in 20 of 28 procedures (71.4%). Pathological indications included advanced atherosclerosis of the carotid arteries (15), past radiotherapy (4), failed stenting (3), resection of carotid body tumour (2), trauma (1), reoperation on a failed graft (1), carotid aneurysm (1) and iatrogenic carotid occlusion (1). An autogenous vein was used in 16, PTFE in 11 and autogenous artery in 1 of the patients. Using the Kaplan-Meier method, the overall patient cumulative 5-year survival was 84% and cumulative 5-year stroke-free survival was 93%. The combined perioperative stroke and mortality rate was 7.1%. Two patients had transient ischaemic attacks (7.1%), one had cranial nerve palsies (3.6%) and one required reoperation for bleeding (3.6%). Five-year cumulative graft primary patency using the Kaplan-Meier method was 74% for PTFE grafts and 92% for autogenous vein grafts (P = 0.37). CONCLUSION: Carotid artery bypass is a safe and a useful treatment option for complex extra-cranial arterial disease. Either PTFE or autogenous veins may be used as conduits.