Axilloaxillary bypass for the treatment of subclavian artery stenosis complicated by bilateral common carotid artery occlusion: technical case report

Subclavian Artery-Carotid Artery Bypass for Subclavian Artery or Common Carotid Artery Severe Stenosis or Occlusion

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

Occlusion of all aortic arch great vessels: acute revascularization to perform endovascular stroke therapy

BACKGROUND

We present a case of a patient with a left-sided stroke and occlusion of all aortic arch great vessels who was treated successfully with endovascular intervention followed by delayed cardiothoracic revascularization.

CASE REPORT

A 46-year-old man presented with acute onset of dense right hemiparesis, facial droop, and aphasia with an initial National Institute of Health Stroke Score of 15. The patient was taken for emergent angiography after failing intravenous tissue plasminogen activator thrombolysis. Dedicated angiography of the aortic arch revealed occlusion of all great vessels, including the right brachiocephalic, left common carotid, and left subclavian artery. Delayed arterial filling of the right brachiocephalic and left subclavian artery by aberrant collaterals was seen. More distally, flow into the bilateral subclavian arteries, right common carotid artery, and left vertebral artery was appreciated. Serial balloon angioplasty of the left common carotid artery origin reconstituted flow. Subsequent selective angiogram of the left internal carotid artery revealed a proximal middle cerebral artery occlusion. Intra-arterial injection of tissue plasminogen activator followed by mechanical thrombectomy and intracranial stenting restored flow in the middle cerebral artery. Two months later the patient underwent aortic arch reconstruction with bifurcated graft to the brachiocephalic artery and left common carotid artery. At 1-year follow-up, the patient's examination revealed almost complete resolution of right hemiparesis with minimal hand weakness and mild expressive aphasia.

CONCLUSIONS

We report a rare case of occlusion of all aortic arch great vessels. Combined endovascular intervention and surgical revascularization resulted in an excellent durable outcome.

Bilateral occlusion associated to steal phenomenon of internal carotid and left subclavian arteries: treatment by angioplasty and stenting

OBJECTIVE

Treatment of subclavian artery occlusion is still a matter of controversy due to the short- and long-term complications and patency issues. We report an unusual case of combined occlusion of the proximal segment of the left subclavian artery and subclavian steal phenomenon associated with bilateral occlusion of the internal carotid arteries.

CASE DESCRIPTION

A 55-year-old male patient with previous history of myocardial infarction and hypertension presented with amblyopia and recurrent dizziness, mainly at work. Doppler fluxometry and digital subtraction angiography depicted proximal left subclavian artery occlusion and subclavian steal. Internal carotid arteries were occluded at the common carotid artery bifurcation. Percutaneous transluminal angioplasty and stenting (PTAS) were successfully performed by the left radial artery approach without complications. The patient had no recurrence of the symptoms, and the angiographic follow-up at 1 year showed good patency of the subclavian artery and normal flow through the left vertebral artery.

CONCLUSION

The planned approach for the case (PTAS) was performed without complications and evidence of restenosis in the angiography study at the completion of the first year of the treatment. The described strategy is safe and should be considered the first-choice procedure in the treatment of the subclavian occlusion.

Bilateral common carotid artery occlusion--a case report and literature review

Although unilateral common carotid artery (CCA) occlusion and bilateral internal carotid artery (ICA) occlusion have been reported in the past, bilateral CCA occlusion is rare. The management and mechanism of unilateral CCA occlusion and bilateral ICA occlusion are debatable, but those of bilateral CCA occlusion are largely unknown. Herein, we present a case of bilateral CCA occlusion that had an acceptable outcome with medical treatment. The literature regarding unilateral CCA occlusion, bilateral ICA occlusion and bilateral CCA occlusion is also discussed. Experience implies that the collateral circulation gives rise to the clinical presentation, and may affect the outcome of various managements. Our review and case study may provide new information for future studies of carotid artery occlusion.