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 reconstructions (SAT) performed over 16 years.

METHODS: There were eight innominate endarterectomies and 92 bypass procedures based on the thoracic aorta (n = 86) or proximal innominate artery (n = 6) in 98 patients 24 to 79 years of age. Indications included cerebrovascular ischemia in 83 and upper extremity ischemia in four. Thirteen patients were asymptomatic. An innominate lesion was bypassed in 78 cases. The left common carotid and left subclavian arteries required reconstruction in 38 and 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 patients underwent concomitant cardiac surgery.

RESULTS: Eight deaths and eight 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 graft occlusions, three nonfatal myocardial infarctions, seven significant pulmonary complications, three sternal wound infections, and one recurrent laryngeal nerve injury. Follow-up ranged from 1 to 184 months (mean, 51 +/- 4.8 months). Eight patients were lost to follow-up. Twenty-one late deaths occurred. Two SATs required late revision. The cumulative primary patency rates at 5 and 10 years were 94% +/- 3% and 88% +/- 6%, respectively. The stroke-free survival rates at 5 and 10 years were 87% +/- 4% and 81% +/- 7%, respectively. Patients who survived beyond 30 days had a median stroke-free life expectancy of 10 years, 7 months (SE, 6%).

CONCLUSIONS: Direct reconstruction of complex symptomatic SAT lesions can be performed with acceptable death/stroke rates and with long-term patient benefit. Asymptomatic lesions in patients who have significant concomitant conditions should be managed with a less-morbid cervical or endovascular approach, even if long-term outcome of the latter is inferior.