Carotid to Carotid Bypass Grafting for Brachiocephalic Artery Stenosis

Figure 1. Aortic arch angiogram demonstrating stenosis (arrow) at the origin of the braciocephalic artery

During a routine medical examination, a 54-year-old man was noted to have a reduced volume right brachial and radial pulse, together with a right subclavian bruit. He had no symptoms. Blood pressure on the right arm measured 110/60 mmHg compared with 150/70 mmHg on the left. Past medical history included hyperlipidaemia and cigarette usage of 20 per day.

Angiography demonstrated a 75% stenosis at the origin of the right brachiocephalic artery. Fourteen months later, this had progressed to a 90% eccentric stenosis with post-stenotic dilatation [Fig 1]. A decision to operate was made after discussion with the patient.

Under general anaesthesia, a right common carotid artery to left common carotid artery bypass was fashioned using a 6mm impregnated Dacron graft. Bilateral oblique incisions anterior to the border of sternomastoid were made. The platysma muscle was divided, sternomastoid retracted and both vagus nerves identified and preserved. Both common carotid arteries were dissected out. The graft was tunneled beneath platysma and sutured end to side into each common carotid artery using 5/0 polypropelene suture.

 At follow up the graft could be seen crossing the anterior part of the neck [Fig 2].

 Angiography confirmed excellent flow in the graft [Fig 3].

Figure 2. Carotid to carotid graft (arrow) crossing the anterior part of the neck	Figure 3. Follow up angiogram showing patent graft (arrow)

References

1. DeBakey ME, Crawford ES, Cooley DA, Morris GC Jr. Surgical considerations of occlusive disease of innominate, carotid, subclavian, and vertebral arteries. Ann Surg 1959;149:690

2. Ozsvath KJ, Roddy SP, Clement Darling III R, et al. Carotid-carotid crossover bypass: Is it a durable procedure. J Vasc Surg 2003;37:582