Common brachiocephalic trunk: Strategies for revascularization

Background. A common brachiocephalic trunk, in which both common carotid ar teries and the right subclavian artery arise from a single trunk off the ar ch, is a normal variant of aortic arch branching that occurs in approximate ly 10% of the population. Because three of the four primary sources of cere bral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revasc ularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy. Methods. A retrospective review of our experience with innominate artery re vascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997 All patients were sympto matic, with either total occlusion (n = 3) or critical stenosis (n = 3) cau sed by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revasculari zation was achieved by a prosthetic bypass graft from the ascending aorta t o the innominate or left common carotid arteries or both (n = 5); or transa rterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessel s was performed in 3 patients. Results. There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital disch arge. One patient developed cerebral hyperperfusion syndrome 1 week after e ndarterectomy that resolved without sequelae with antihypertensive medicati ons. During a follow-up period ranging from 1 to 20 years, there was one la te death from congestive heart failure 5 years after operation. All survivi ng patients are alive and free from symptomatic recurrence. Conclusions. Revascularization for occlusive disease of a common brachiocep halic trunk can be achieved with effective and durable relief of symptoms u sing either a prosthetic bypass graft or endarterectomy. However, neurologi c complications in 2 patients, which were fatal in 1, attest to the potenti al cerebral ischemic threat posed by occlusive disease of a common brachioc ephalic trunk. (Ann Thorac Surg 1999;67:657-60) (C) 1999 by The Society of Thoracic Surgeons.