Subclavian artery revascularization: A decade of experience with extrathoracic bypass procedures

Extrathoracic revascularization has become the most popular form of surgical correction of symptomatic subclavian artery lesions. During a 10-year period ending in December 1991, 41 extrathoracic bypass procedures were performed on 37 patients for proximal subclavian artery stenosis or occlusion. This included 25 females and 12 males, with a mean age of 56 years. Surgery was performed for manifestations of upper extremity ischemia in 19 patients (51%), vertebrobasilar insufficiency in four patients (11%), and both upper extremity ischemia and vertebrobasilar insufficiency in 11 patients (30%). Three patients (8%) had angina pectoris caused by “coronary-subclavian steal” following internal mammary-coronary artery bypass. Severe proximal stenosis or complete occlusion of the subclavian artery was demonstrated angiographically in all cases. Procedures performed included: carotid-subclavian bypass (n = 28), subclavian-carotid transposition (n = 6), axilloaxillary bypass (n = 4), and subclavian-subclavian bypass (n = 3). Saphenous vein was used as the bypass conduit in 6 of the carotid-subclavian bypass procedures, and prosthetic grafts were used for the remainder. There were no perioperative strokes or deaths in this series, and the mean postoperative hospital stay was 4 days. Follow-up ranged from 2 to 96 months (mean, 35.6 months). The overall patency rate was 95% at 1 year, 86% at 3 years, and 73% at 5 years. Patency at 5 years was significantly higher for procedures utilizing the common carotid artery as the donor vessel as compared with those using the contralateral subclavian or axillary arteries (83% versus 46%, P < 0.01). Two patients had recurrence of symptoms despite patency of the graft, and there was one death during the follow-up period that was unrelated to the revascularization procedure. This experience shows that extrathoracic bypass procedures are efficient, safe, and well-tolerated and offer long-term patency in the treatment of symptomatic subclavian stenosis or occlusion. Whenever possible, the ipsilateral common carotid should be used as the donor artery in these cases.