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Subclavian Artery Revascularization: An Outcome Analysis Based on Mode of Therapy and Presenting Symptoms

Published:December 17, 2007DOI:https://doi.org/10.1016/j.avsg.2007.07.020
      Therapy for atherosclerotic occlusive subclavian arterial disease is undergoing a paradigm shift from open to endoluminal therapy. The aim of this study was to review the changing patterns of presentation and clinical outcomes based on presenting symptoms of subclavian artery revascularization. We performed a retrospective analysis of consecutive patients treated for symptomatic atherosclerotic occlusive subclavian arterial disease from 1992 through 2006. Mean follow-up was 4 years. One hundred fourteen patients with a mean age of 63 years (range 33-89, 61% female) underwent 137 procedures. Of these, 89% had hypertension, 32% were diabetic, 69% had hyperlipidemia, and 13% had chronic renal insufficiency. Sixty-seven primary stent attempts (five technical failures) and 70 open (64 carotid–subclavian bypasses, six subclavian–carotid transpositions) were performed. No deaths occurred within the 30-day perioperative period. Fifty-seven percent of the patients presented with symptoms of arm ischemia: exertional pain (84%), rest pain (12%), and ulceration (4%). The assisted primary patency was 81 ± 7% and 80 ± 10% at 5 and 10 years, respectively. Symptoms resolved in all patients, and none required major or minor amputations. Freedom from recurrent arm symptoms was 71 ± 8% and 71 ± 10% at 5 and 10 years, respectively. Twenty-five percent of the patients presented with a cardiac indication: preparation for a left internal mammary artery (IMA) bypass in 61% and recurrent cardiac ischemia in the remainder. The assisted primary patency was 97 ± 6% at 5 years. No IMAs were abandoned in this group, and the freedom from recurrent cardiac symptoms related to IMA distribution was 79 ± 10% at 5 years. Eighteen percent of patients presented with posterior circulation symptoms secondary to vertebrobasilar disease. The assisted primary patency was 100 ± 0% and 100 ± 0% at 5 and 10 years, respectively. Freedom from recurrent vertebrobasilar symptoms was 95 ± 6% and 95 ± 10% at 5 and10 years, respectively. Subclavian artery revascularization is safe and effective, but long-term outcomes are determined by the presenting symptomatology.
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      References

        • AbuRahma A.F.
        • Robinson P.A.
        • Jennings T.G.
        Carotid-subclavian bypass grafting with polytetrafluoroethylene grafts for symptomatic subclavian artery stenosis or occlusion: a 20-year experience.
        J Vasc Surg. 2000; 32: 411-419
        • Westerband A.
        • Rodriguez J.A.
        • Ramaiah V.G.
        • Diethrich E.B.
        Endovascular therapy in prevention and management of coronary–subclavian steal.
        J Vasc Surg. 2003; 38: 699-704
        • Edwards W.H.
        • Tapper S.S.
        • Edwards W.H.S.
        • Mulherin J.L.J.
        • Martin R.S.
        • Jenkins J.M.
        Subclavian revascularization. A quarter century experience.
        Ann Surg. 1994; 219: 673-677
        • Uurto I.T.
        • Lautamatti V.
        • Zeitlin R.
        • Salenius J.P.
        Long-term outcome of surgical revascularization of supra-aortic vessels.
        World J Surg. 2002; 26: 1503-1506
        • Vitti M.J.
        • Thompson B.W.
        • Read R.C.
        • et al.
        Carotid–subclavian bypass: a twenty-two-year experience.
        J Vasc Surg. 1994; 20: 411-418
        • Ballotta E.
        • Da Giau G.
        • Abbruzzese E.
        • Mion E.
        • Manara R.
        • Baracchini C.
        Subclavian carotid transposition for symptomatic subclavian artery stenosis or occlusion. A comparison with the endovascular procedure.
        Int Angiol. 2002; 21: 138-144
        • de Vries J.P.M.
        • Jager L.C.
        • van den Berg J.C.
        • et al.
        Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: long-term results.
        J Vasc Surg. 2005; 41: 19-23
        • Henry M.
        • Mor M.
        • Henry I.
        • Ethevenot G.
        • Tzvetanov K.
        • Chati Z.
        Percutaneous transluminal angioplasty of the subclavian arteries.
        J Endovasc Surg. 1999; 6: 33-41
        • Rodriguez-Lopez J.A.
        • Werner A.
        • Martinez R.
        • Torruella L.J.
        • Ray L.I.
        • Diethrich E.B.
        Stenting for atherosclerotic occlusive disease of the subclavian artery.
        Ann Vasc Surg. 1999; 13: 254-260
        • Sullivan T.M.
        • Gray B.H.
        • Bacharach J.M.
        Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients.
        J Vasc Surg. 1998; 28: 1059-1065
        • Farina C.
        • Mingoli A.
        • Shultz R.D.
        • et al.
        Percutaneous transluminal angioplasty versus surgery for subclavian artery occlusive disease.
        Am J Surg. 1989; 158: 511-514
        • Rutherford R.B.
        • Baker J.D.
        • Ernst C.
        • et al.
        Recommended standards for reports dealing with lower extremity ischemia: revised version.
        J Vasc Surg. 1997; 26: 517-538
        • Aboyans V.
        • Criqui M.H.
        • McDermott M.M.
        • et al.
        The vital prognosis of subclavian stenosis.
        J Am Coll Cardiol. 2007; 49: 1540-1545
        • Bates M.C.
        • Broce M.
        • Lavigne P.S.
        • Stone P.
        Subclavian artery stenting: factors influencing long-term outcome.
        Catheter Cardiovasc Interv. 2004; 61: 5-11
        • Lyons C.
        • Gailbraiter G.
        Surgical treatment of atherosclerotic occlusion of the internal carotid artery.
        Ann Surg. 1957; 146: 487-494
        • Parrott J.C.
        The subclavian steal syndrome.
        Arch Surg. 1964; 88: 661-665
        • Modarai B.
        • Ali T.
        • Dourado R.
        • Reidy J.F.
        • Taylor P.R.
        • Burnand K.G.
        Comparison of extra-anatomic bypass grafting with angioplasty for atherosclerotic disease of the supra-aortic trunks.
        Br J Surg. 2004; 91: 1453-1457
        • Ferrara F.
        • Meli F.
        • Raimondi F.
        Subclavian stenosis/occlusion in patients with subclavian steal and previous bypass of internal mammary intraventricular anterior artery: Medical or surgical treatment?.
        Ann Vasc Surg. 2004; 18: 566-571
        • Hadjipetrou P.
        • Cox S.
        • Piemonte T.
        • Eisenhauer A.
        Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels.
        J Am Coll Cardiol. 1999; 33: 1238-1245
        • Kandarpa K.
        • Becker G.J.
        • Hunink M.
        • et al.
        Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part I.
        J Vasc Interv Radiol. 2001; 12: 683-695
        • Schillinger M.
        • Haumer M.
        • Schillinger S.
        • Ahmadi R.
        • Minar E.
        Risk stratification for subclavian artery angioplasty: is there an increased rate of restenosis after stent implantation?.
        J Endovasc Ther. 2001; 8: 550-557
        • Rigatelli G.
        • Cardaioli P.
        • Giordan M.
        • et al.
        Peripheral vascular disease endovascular management in patients scheduled for cardiac surgery: a clinical-angiographic approach.
        Int J Cardiovasc Imaging. 2006; 22: 305-310
        • Patel P.
        • Shammas N.W.
        • Kapalis M.J.
        • Dippel E.J.
        • Lemke J.
        • Harb C.
        Routine visualization of the left internal mammary artery before bypass surgery: is it necessary?.
        J Invasive Cardiol. 2005; 17: 479-481
        • Takach T.J.
        • Reul G.J.
        • Cooley D.A.
        • et al.
        Myocardial thievery: the coronary–subclavian steal syndrome.
        Ann Thorac Surg. 2006; 81: 386-392
        • Angle J.F.
        • Matsumoto A.H.
        • McGraw J.K.
        • et al.
        Percutaneous angioplasty and stenting of left subclavian artery stenosis in patients with left internal mammary–coronary bypass grafts: clinical experience and long-term follow-up.
        Vasc Endovascular Surg. 2003; 37: 89-97
        • Thomassen L.
        • Aarli J.A.
        Subclavian steal phenomenon. Clinical and hemodynamic aspects.
        Acta Neurol Scand. 1994; 90: 241-244