Jacob Quick, Colleen S. Hupp, Rumi Faizer
University of Missouri, Columbia, MO.
BACKGROUND: Complex cerebrovascular lesions require careful operative planning. We present a case of a 59-year-old male with a history of recent transient ischemic attack and right subclavian steal symptoms. Carotid duplex and CT angiography showed an aberrant left vertebral artery with critical origin stenosis, left common carotid artery (CCA) critical origin stenosis, and an occluded innominate artery extending to the right CCA bulb. This presented multiple therapeutic options including antegrade or retrograde endovascular stenting of the left CCA, with or without femoral to axillary bypass on the right to protect cerebral perfusion. We chose an alternate strategy made available by the normal left subclavian: a left subclavian to right carotid bypass, with branched grafts to the left CCA and left vertebral. No complications occurred. Follow up angiography demonstrated full-patency of the grafts and the patient has been without symptoms for greater than one year.
TECHNICAL DESCRIPTION: We begin with an outline of the anatomy and the options. We then present the operation, first with a left transverse supraclavicular incision through which the phrenic nerve is preserved and the left CCA, subclavian, and vertebral arteries are circumferentially controlled. Next, through a separate incision we expose and control the right carotid vessels. We then create a retroesophageal tunnel through which we pass a ringed 6 mm graft between the two incisions. Two short 6 mm branches are then sewn into place on the left side of the graft. These are occluded with hemoclips and we proceed with the left subclavian and right carotid anastomoses. Once antegrade right carotid flow is instituted, we then perform anastomoses of the graft branches to the left CCA and vertebral arteries, without interrupting flow to the right carotid. The hemoclips are then removed to restore flow through the left CCA and vertebral arteries. Pulsatile flow is confirmed and the wounds are closed.
AUTHOR DISCLOSURES: R. Faizer, Nothing to disclose; C. S. Hupp, Nothing to disclose; J. Quick, Nothing to disclose.
Posted April 2012