Safety and Durability of Concomitant Carotid Endarterectomy With Carotid Subclavian Bypass Grafting.

BACKGROUND: Concomitant carotid endarterectomy (CEA) (for severe internal carotid artery (ICA) stenosis) and carotid subclavian bypass (CSBP) grafting (for proximal common carotid artery (CCA) or subclavian artery occlusions) is rarely utilized with only few studies were reported. This report will analyze early and late clinical outcome of the largest study to date of the combined procedures in our institution.

METHODS: Electronic medical records of patients who had concomitant CEA with CSBP over 3 decades were analyzed.

INDICATIONS: arm ischemia, neuro events, and clinical subclavian steal. Early (30 days) perioperative (stroke, death and others) and late complications (stroke, death) were recorded. Kaplan-Meier Analysis was used to estimate late graft/CEA primary patency, freedom of stroke and stroke free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound (DUS). Outcomes were compared with previously published data on isolated CSBP grafting by the same group.

RESULTS: 37 combined procedures were analyzed. Mean age was 64 years (range 45-81). Indications for surgery were: arm ischemia in 12/37 (32%), hemispheric TIA/stroke in 15/37 (41%), vertebrobasilar insufficiency (VBI) in 4/37 (11%), symptomatic subclavian steal in 10/37 (27%) and asymptomatic CCA occlusion with severe ICA stenosis in 6/37 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100% with 2.7% (TIA) symptom recurrence. The crude patency rate of both CEA/CSBP grafts was 92%. Primary patency rates were 100%, 96%, 96%, 96% and 85% (Figure 1), freedom from stroke rates were 97%, 97%, 97%, 97% and 97%, and stroke free survival rates were 94%, 94%, 87%, 82% and 78% all at 1 ,2 ,3, 4 and 5 years, respectively. When these outcomes were compared with the isolated CSBP grafting group alone (28 patients), there was no difference in perioperative stroke: 2.7% for concomitant CEA/CSBP vs 0% for isolated CSBP; perioperative death: 2.7% vs 2.8% or late patency rates (92% vs 96%).

CONCLUSIONS: Concomitant CEA/CSBP grafting is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates, when compared with isolated CSBP grafting.