Extrathoracic arterial grafts performed for carotid artery occlusive disease not amenable to endarterectomy

Hypothesis: Extrathoracic cervical grafts are safe and provide long-lasting stroke prevention in patients with disease not amenable to standard caroti d bifurcation endarterectomy. Design: Review of a prospectively maintained vascular surgical registry. Setting: Combined university and Department of Veterans Affairs vascular su rgical service. Participants: Patients requiring surgery for carotid atherosclerotic occlus ive disease not amenable to endarterectomy from January 1988 to March 1998. Interventions: Carotid interposition grafting, subclavian-carotid bypass, o r carotid-carotid bypass. Main Outcome Measures: Perioperative stroke and death, and life-table deter mination of freedom from stroke, stroke-free survival, and graft patency. Results: Sixty patients (mean age, 65.8 years; range, 36-83) underwent cerv ically based carotid grafting. All had greater than 70% stenosis or occlusi on of the innominate, common carotid, or internal carotid arteries, and 30 (50%) had undergone at least 1 previous ipsilateral carotid endarterectomy. Indication for operation was stroke or transient ischemic attack in 46 (77 %) and asymptomatic high-grade stenosis in 14 (23%). Operative procedures i ncluded 31 (52%) carotid interposition grafts, 18 (30%) subclavian-carotid grafts, and 11 (18%) carotid-carotid grafts. Mean follow-up was 29 months ( range, 1-117 months). Perioperative stroke rate was 5% (3/60) all in sympto matic patients, and there were no perioperative deaths. By life-table analy sis, freedom from stroke was 92% atl and 5 years. Stroke-free survival was 90% at 1 year and 61% at 5 years. Primary graft patency was 94% at 1 year a nd 84% at 5 years, with assisted primary patency of 90% at 5 years. Conclusion: Cervical carotid artery grafts for complicated or recurrent car otid atherosclerosis not amenable to endarterectomy are durable and provide excellent freedom from stroke with low perioperative morbidity and mortali ty.