Subclavian-carotid bypass graft for the occlusion of the common carotid artery

Abstracts

A oclusão isolada da artéria carótida comum (ACC) é uma lesão relativamente incomum (0,5 a 5%). A maioria dos pacientes com obstrução da ACC tem lesão concomitante na artéria carótida interna (ACI) e na artéria carótida externa (ACE) ipsilaterais, sendo que, ocasionalmente, a circulação colateral da ACE pode preservar a perviedade da ACI via fluxo retrógrado. Relatamos o caso de um paciente sintomático com oclusão da ACC e perviedade das ACI e ACE tratado cirurgicamente com enxerto subclávio-carotídeo.

Enxerto subclávio-carotídeo; oclusão artéria carótida; doença cerebrovascular

CASE REPORT

Subclavian-carotid bypass graft for the occlusion of the common carotid artery

Otacílio de Camargo Junior^I; Luiz Roberto Felizzola^II; Antonio Cláudio Guedes Chrispim^II; Claudio Roberto Cabrini Simões^II; Márcia Fayad Marcondes^III; Marivan Pedra Araújo^III; Kelly Cristina Moraes^III; Márcio Villar de Freitas^III

^IProfessor adjunto, Chefe do Serviço de Angiologia e Cirurgia Vascular, Hospital e Maternidade Celso Pierro (HMCP), Campinas, SP, Brazil

^IIMédico, Serviço de Angiologia e Cirurgia Vascular, HMCP, Campinas, SP, Brazil

^IIIResidente, Serviço de Angiologia e Cirurgia Vascular, HMCP, Campinas, SP, Brazil

Correspondence

ABSTRACT

Isolated occlusion of the common carotid artery (CCA) is a relatively uncommon lesion (0.5 to 5%). Most patients with occlusion of the CCA have concomitant lesions of the ipsilateral internal carotid artery (ICA) and external carotid artery (ECA), and ECA may occasionally preserve ICA patency by means of retrograde flow. We report the case of a symptomatic patient with occlusion of the CCA and patency of the ICA and ECA treated with subclavian-carotid bypass graft.

Keywords: Subclavian-carotid bypass, carotid artery occlusion, cerebrovascular disease.

Introduction

Isolated occlusion of the common carotid artery (CCA) is a relatively uncommon lesion (0.5 to 5% of cerebral ischemia patients).¹ Most patients with CCA obstruction have a concomitant lesion in ipsilateral internal carotid artery (ICA) and external carotid artery (ECA). Occasionally, ECA collateral circulation may preserve ICA's patency via retrograde perfusion through carotid bulb.² A variety of procedures is used for the reconstruction of the arterial flow in this type of anatomic variant. The techniques used include subclavian-carotid, axillary-carotid, and carotid-carotid grafts, all of them with or without simultaneous endarterectomy; CCA carotid endarterectomy; and aortic-carotid graft.^2,3 Subclavian-carotid graft is the most widely used and safer procedure according to literature.^1,2,4-6 We describe a case in which such technique was used.

Case Report

Male, 75-year-old patient, hypertensive and smoker, with history of ischemic stroke 3 months earlier, with motor sequela partially reverted in upper right limb. The stroke was verified by computed tomography (CT). Carotid Doppler ultrasound evidenced occlusion in left common carotid artery (LCCA); flow inversion in the left external carotid artery (LECA); left internal carotid artery (LICA) with thickened walls and flow originating from LECA; pervious right common carotid artery (RCCA), right internal carotid artery (RICA) and right external carotid artery (RECA), although with walls thickened by calcified plaques. The use of antiplatelet drug was indicated, and anti-hypertensive medications were maintained. An arteriography was required, confirming LCCA occlusion with collateral circulation to LECA and LICA filling. RCCA, RICA, and RECA presented irregular outlines and preserved calibres; a dominant right vertebral artery with critical ostial stenosis was identified, as well as hypoplastic left vertebral artery.(Figure 1) One week after arteriography was performed, the patient presented a picture of transitory ischemic stroke again with motor deficit in upper right limb, accompanied by episodes of dizziness. The use of antiplatelets and anti-hypertensive drugs was maintained and a new carotid Doppler ultrasound was required, evidencing LICA's patency with flow from LECA. The patient was submitted to endarterectomy of the carotid bifurcation (LCCA, LICA, and LECA) with the performance of left subclavian carotid bypass graft with 6 mm polytetrafluoroethylene (PTFE) prosthesis.(Figures 2 e 3) Surgical procedure was performed under general anesthesia withou the need of temporary derivation. The patient evolved asymptomatically, being discharged from hosptial in the third post-operative day. Carotid Doppler ultrasound and arteriography required 6 months after the surgery evidenced the patency of left sublcavian-carotid graft, but with the occlusion of LECA and right vertebral artery.(Figure 4) The patient remains being followed up in out-patient clinic for 2 years, with no new neurological symptoms.

Discussion

Although the dominant localization of symptomatic carotid disease of the carotid artery is in the carotid bifurcation, lesions in the proximal ACC cause similar symptoms.⁷ The risk factors for occlusive artery disease include smoking (76%), hypertension (71%), diabetes mellitus (41%) and hyperlipidemia (41%). In 82% of cases two or more risk factors are included. Cardiac defects are present in 59% of the patients.⁸ The mechanisms of the symptoms are multifactorial and the same as those of the disease localized in the ICA and the carotid bifurcation.⁹ Patients who suffer from the CCA occlusion present risk of hemispheric transitory ischemic attacks, stroke or vertebrobasilar symptoms.¹⁰

Dominant signs and symptoms include visual monocular symptoms and ipsilateral retrochiasms (88%), loss of motor force (88%), sensorial disturbances (59%), amaurosis fugax (53%) and syncope (24%). The AITs are generally multiple and they preced a stroke, or occur with no subsequent stroke in 82% of cases.⁸ Historically, the diagnosis of CCA occlusion was made through cerebral arteriography or blindfold exploration of the carotid bifurcation. More recently, Doppler ultrasound has been used for diagnosis and it permits the accurate and proper localization of the carotid bifurcation.^1,10 Surgical indications for CCA obstruction include AIT episode, stroke, non-focal vertebrbasilar failure symptoms (syncope, vertigo) compatible with complementary exam.^4,5,11,12 The restoration of the carotid artery flow through subclavian artery based on an extra-anatomical graft will provide an adequate reconstruction for the obstruction of the CCA.⁷ Various studies have shown that the subclavian-carotid graft is the most widely used procedure in the occlusion of CCA and an excellent surgical option, because it presents good long term results and significant reduction of the symptoms in post-operative.^1,3,10 In relation to the type of graft used, Ziomek et al.⁶ have obtained better results with the use of prosthesis (91% of patent grafts in the cases in which prosthesis was used, and 57% in cases with veins). Vitti et al.⁵ performed a retrospective study with 124 patients in whom the graft with prosthesis was used in all the cases (35% PTFE and 65% dacron) with patency rates of 95% in 5 years and survival rates without symptoms of 90% in 5 years. On their turn, Defraigne et al.⁹ have performed a subclavian-carotid graft in 29 patients. In 15 cases, saphenous vein was used, and 14 were performed with prosthesis, with no existing difference in patency between materials used (89% in 40 months for both). Salam et al.⁴ have used saphenous vein in 65% of grafts performed and obtained patency rate of 90% in 3 years. Ultimately, recognizing distal patency of arteries above the CCA occlusion depends on a high index of suspicion, careful investigation of the carotid bulb with duplex scan and/or arteriography for investigation of the refilling through collateral arteries.² It can be concluded, therefore, that patients with CCA occlusion and patency above the occlusion may be surgically treated through the confection of the subclavian-carotid graft. This procedure has shown to be, according to the studied publications, safe, effective, with low morbidity and mortality and good results in follow up, regardless of the type of material used for the graft, being it the most common one currently performed.^1,3-5,9,10

References

• 1. Adovasio R, Visitin E. Il by-pass succlavio-carotideo quale metódica di trattamento dell'ostruzione della carotide comune. Ann Ital Chir. 1999;70:247-50.
• 2. Belkin M, Mackey WC, Pessin M, et al. Common carotid occlusion with patent internal and external carotid arteries: diagnosis and surgical management. J Vasc Surg. 1993;17:1019-28.
• 3. Dellaretti Filho MA, de Sousa AA, Carvalho GT; de Castro MF. Occlusion of the common carotid artery treated with a subclavian-internal carotid artery bypass. Arq Neuropsiquiatr. 2003;61:453-5.
• 4. Salam TA, Smith RB 3rd, Lumsden AB. Extrathoracic bypass procedures for proximal common carotid artery lesions. Am J Surg. 1993;166:163-7.
• 5. Vitti MJ, Thompson BW, Read RC, Gagne PJ, Barone GW, Barnes RW, Eidt JF. Carotid-subclavian bypass: a twenty-two-year experience. J Vasc Surg. 1994;20:411-8.
• 6. Ziomek S, Quiñones-Baldrich WJ, Busuttil RW, et al. The superiority of synthetic arterial grafts over autologous veins in carotid-subclavian bypass. J Vasc Surg. 1986;3:140-5.
• 7. Fry WR, Martín JD, Clagett GP, et al. Extrathoracic carotid reconstruction: the subclavian-carotid artery bypass. J Vasc Surg. 1992;15:83-9.
• 8. Levine SR, Welch KMA. Common carotid artery occlusion. Neurology. 1989;39:178-86.
• 9. Defraigne JO, Remy D, Creemers E, Limet R. Carotid-subclavian bypass with or without carotid endarterectomy. Acta Chir Belg. 1990;90:248-54.
• 10. Sullivan TM. Subclaviacarotid bypass to an "isolated" carotid bifurcation: a retrospective analysis. Ann Vasc Surg. 1996;10:283-9.
• 11. Martín SR 3rd, Edwards WH, Mulherin JL. Surgical treatment of common carotid artery occlusion. Am J Surg. 1993;165:302-6.
• 12. Perler BA, Williams GM. Carotid-subclavian bypass: a decade of experience. J Vasc Surg. 1990;12:716-23.

Publication Dates

• Publication in this collection
  01 Sept 2010
• Date of issue
  2010

History

• Received
  11 Sept 2009
• Accepted
  29 Oct 2009