TRANSTHORACIC REPAIR OF INNOMINATE AND COMMON CAROTID-ARTERY DISEASE - IMMEDIATE AND LONG-TERM OUTCOME FOR 100 CONSECUTIVE SURGICAL RECONSTRUCTIONS

Purpose: This is a review of 100 consecutive supraaortic trunk reconst ructions (SAT) performed over 16 years. Methods: There were eight inno minate endarterectomies and 92 bypass procedures based on the thoracic aorta (n = 86) or proximal innominate artery (n = 6) in 98 patients 2 4 to 79 years of age. Indications included cerebrovascular ischemia in 83 and upper extremity ischemia in four. Thirteen patients were asymp tomatic. An innominate lesion was bypassed in 78 cases. The left commo n carotid and left subclavian arteries required reconstruction in 38 a nd nine patients, respectively. Multiple trunks were reconstructed by direct bypass grafting in 35. Approach was via median sternotomy in 92 , partial sternotomy in six, and left thoracotomy in two. Seven patien ts underwent concomitant cardiac surgery. Results: Eight deaths and ei ght nonfatal strokes occurred, for a combined stroke/death rate of 16% . The operative mortality rate was 6% for SAT and 29% for SAT/cardiac operations. Perioperative complications included two asymptomatic graf t occlusions, three nonfatal myocardial infarctions, seven significant pulmonary complications, three sternal wound infections, and one recu rrent laryngeal nerve injury Follow-up ranged from 1 to 184 months (me an, 51 +/- 4.8 months). Eight patients n ere lost to follow-up. Twenty -one late deaths occurred. Two SATs required late revision. The cumula tive primary patency rates at 5 and 10 years were 94% +/- 3% and 8846 +/- 6%, respectively. The stroke-free survival rates at 5 and 10 years were 87% +/- 4% and 81% +/- 7%, respectively. Patients who survived b eyond 30 days had a median stroke-free life expectancy of 10 years, 7 months (SE, 6%). Conclusions: Direct reconstruction of complex symptom atic SAT lesions can be performed with acceptable death/stroke rates a nd with long-term patient benefit. Asymptomatic lesions in patients wh o have significant concomitant conditions should be managed with a les s-morbid cervical or endovascular approach, even if long-term out-come of the latter is inferior (J Vasc Surg 1998;27:34-42.).