Management of subclavian and innominate artery injuries.

Subclavian and innominate arterial injuries are life-threatening and require aggressive treatment. Physical findings, chest x-ray examinations, and a high index of suspicion led to expoloration in seventeen of twenty-two patients in this series, but the selective use of arteriography is helpful. Primary repair was accomplished in nineteen of the twenty-two patients. Wide proximal exposure proved to be accompanied by little morbidity with the reward of increasing survival to 95.5 per cent.     

Intrathoracic aneurysm of the right subclavian artery

Arterial aneurysms may occur in all arteries of the human body. Arteriosclerosis takes the first place in the aetiology of the aneurysms of the great arteries and lower extremities. We would like to present a rare atherosclerotic aneurysm in the intrathoracic region of the right subclavian artery, in which vascular continuity was re-established by resection and direct end-to-end anastomosis instead of the generally used resection + revascularization technique with vascular grafts.     

Direct reconstruction of the innominate artery

PURPOSE OF THIS STUDY: Occlusive disease of the innominate artery requiring reconstruction is relatively uncommon. Data concerning these lesions has come from retrospective reviews at larger institutions. The purpose of this paper is to review the most recent experience at the Mayo Clinic, as well as to review the experiences of other large centers in the recent past, and to determine which patients are benefited by direct reconstructions and which patients might be better served by indirect methods or by endovascular techniques. BASIC METHODS: A retrospective analysis of the trends at the Mayo Clinic concerning reconstruction of the innominate artery since 1976 was undertaken. Two reviews from our institution, published in 1989 and 1999, of all patients seen since 1976, were analyzed. This retrospective analysis also included papers from other referral centers dealing with innominate artery reconstruction, both here and in France. PRINCIPAL FINDINGS AND CONCLUSIONS: The great majority of patients with symptomatic disease of the innominate artery are well treated by direct reconstruction. Stroke and death rates are acceptable. Early results are excellent, and the durability of the operation is also excellent, with impressive stroke-free survival rates. There are subsets of patients who might be treated by medical techniques or techniques other than direct reconstruction, such as cervical reconstruction or endovascular repair. Coronary artery disease remains the main determinate of early and late morbidity.     

A new surgical approach to the innominate and subclavian vein

A new technique extending the incision used for thoracic outlet decompression with a subclavicular approach to the first rib is presented. After the first rib and scalenotomy are removed, the subclavicular incision is continued into the sternum medially and superiorly to the sternal notch. This gives easy access to the innominate-subclavian-axillary vein segment. Eight patients with extensive chronic fibrotic obstruction of the subclavian-innominate vein segment underwent operation with this technique. It allows placement of either long patches of saphenous vein to reestablish normal caliber or replacement, as is our choice, with a small-sized cryopreserved descending thoracic aortic homograft. The operation is carried out in an extrapleural plane preserving the sternoclavicular joint, avoiding the deformity caused by transclavicular techniques. Repair of the sternotomy creates a stable incision. Follow-up to 14 months shows patency of the venous channel with no complications. This surgical approach is recommended to solve the problem of satisfactory exposure of the subclavian-innominate venous channel after decompression of the thoracic outlet. (J Vasc Surg 1998;27:576-81.)     

Therapeutic strategy and outcome of stenting for subclavian and innominate artery occlusive disease

We performed stenting for the subclavian artery (SA) and innominate artery occlusive disease in 14 patients between April, 2000 and March, 2003. In 13 of 14 patients, good dilatation was obtained with stenting. In one patient with left SA occlusion, true lumen could not be detained from either proximal or distal sides of the occluded lesion, so stent deployment was not performed. From June, 2002, we performed stenting using combined femoral and brachial approaches in 6 of 8 patients. In patients in whom occlusive lesion existed in the proximal portion of the SA, it was useful strategy to create a "pull-through" system to stabilize the guiding catheter position in the aorta or the proximal portion of the SA, and to protect the vertebral artery (VA) with a balloon catheter. Post-operative morbidity was 0%. Restenosis was manifested in one patient (8%) two years after stent placement, and in-stent PTA was carried out. In stenting for the subclavian and innominate arteries, the pull-through system is considered useful for stabilization of the guiding catheter, and protection of the VA for prevention of distal embolism to the VA.     

Evaluation of axillo-axillary artery bypass for the treatment of subclavian or innominate artery occlusive disease

Because of the higher morbidity and mortality of transthoracic procedures, extrathoracic techniques to revascularize the subclavian or innominate artery, such as carotid subclavian and axillo-axillary artery bypasses have gained wide acceptance. The present work evaluates the results of axillo-axillary bypass in 33 patients who underwent this procedure in the past 13 years. There were 13 males and 20 females with a mean age of 61 years. The occlusive disease was present in the subclavian artery in 19 patients and in the right subclavian artery in 14 patients. Eleven patients presented with central nervous system symptoms and 10 patients complained of ischemic arm symptoms. The remaining 12 patients had both central neurological and upper extremity complaints. Twenty-one of these patients were followed for up to 5 years (mean follow-up 21 months). One patient died during the procedure from myocardial infarction (mortality of 3.03%). Patency of the bypass was determined by palpation of the graft pulse, doppler examination, and brachial arterial pressure determination. The patency rate, after 5 years, calculated by life table analysis, was 72%. In conclusion, axillo-axillary artery bypass can provide durable relief of symptoms with an acceptably high patency rate and low morbidity and mortality. It is the technique of choice in high-risk patients.     

Diagnostic and surgical approach of innominate artery saddle embolus.

Patients with an acute arterial occlusion of the right upper extremity and absent axillary pulse should have a Doppler scan examination before a balloon catheter embolectomy is performed. If there is no arterial pulse detectable, an angiography should be performed afterwards to localize the embolus. In the case of a proximal arterial occlusion of the right arm, the authors recommend this procedure to prevent an embolus dislocation by catheter embolectomy and subsequent cerebral embolization. For direct surgical embolectomy the authors recommend a supraclavicular incision.     

Extraanatomical reconstruction for bilateral intrathoracic subclavian artery aneurysms

Successful extraanatomical repair of bilateral intrathoracic arteriosclerotic subclavian artery aneurysms is reported. Rupture of the left subclavian aneurysm required emergency thoracotomy for proximal and distal ligation. The right subclavian aneurysm was repaired electively. Because of constraints resulting from the arterial anatomy (origin of aneurysm at innominate artery bifurcation), prior operation (coronary artery bypass grafting and repair of aneurysm of the sinus of Valsalva), and the patient's occupation (young, employed craftsman with dominant right hand), an extraanatomical reconstruction was devised to exclude the aneurysm and revascularize the head and arm. The reconstruction consisted of an external ilioaxillary Gore-Tex bypass graft in conjunction with an end-to-end distal subclavian to distal common carotid Gore-Tex graft. This is believed to represent the first reported successful repair of bilateral intrathoracic arteriosclerotic subclavian aneurysms, and the first application of this extraanatomical reconstruction.     

A case of traumatic aneurysm of innominate artery with occlusion of right subclavian artery

A 42-year-old woman with history of chest blunt trauma from an automobile accident 250 days earlier had suffered easy fatigability of the right upper extremity. She had difference of blood pressure between upper extremities, 94/60 mmHg in the right and 126/70 mmHg in the left. Chest CT showed dilation of the innominate artery which compressed the trachea. Aortography showed an aneurysm of the innominate artery and occlusion of the right subclavian artery at its origin. The aneurysm of the innominate artery was resected and replaced with a 6 mm Dacron graft with aid of the external shunt. The right subclavian artery was also reconstructed with same graft. The aneurysm of the innominate artery should be suspected as a rare complication in blunt trauma of the chest.     

Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization

Central venous catheterization is routinely required in a wide range of clinical situations such as hemodynamic monitoring, delivery of blood products and drugs, hemodialysis, total parental nutrition, and management of perioperative fluids. Pseudoaneurysms account for 4% of all innominate artery aneurysms. Clinical presentation may include airway and neurological compression, chest pain, mediastinal syndrome, upper limb ischemia, and hemodynamic instability. We report what we believe is the first documented case of a successful endovascular stent-graft repair of an innominate artery iatrogenic pseudoaneurysm.     

The surgical reconstruction of the proximal subclavian and vertebral artery

Endarterectomy, bypass, or direct arterial anastomosis are used to restore flow in a compromised vertebral or subclavian artery. During 20 years of experience in surgical relief of stenosis of the proximal vertebral and subclavian arteries, we now prefer an anastomosis between the involved vertebral or subclavian artery. We have performed 411 such procedures. There has been one death (0.2%), with reoperation necessary in three patients (0.0%). No neurologic morbidity has been associated with this procedure.     

Coronary bypass surgery using the internal thoracic artery after reconstruction of occluded subclavian artery.

We present two cases with an occluded left subclavian artery requiring coronary artery bypass grafting. A preoperative angiogram confirmed that the subclavian artery, including the internal thoracic artery distal from the occlusion, was thoroughly intact, in both cases. Immediately after reconstructing the subclavian artery using an aortoaxillary bypass with an 8 mm ring-reinforced polytetrafluoroethylene graft, each patient underwent double coronary artery bypass grafting using the affected left internal thoracic artery with either the right internal thoracic artery or a saphenous vein in the same anesthetic setting. Symptomatic relief was excellent. In both cases, a postoperative angiographic study showed good function of the left internal thoracic artery graft supplying blood to the coronary artery through the aortoaxillary bypass graft.