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

Abstract

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.