Combined Cerebral and Lower-Limb Revascularization

Abstract

Brachiocephalic atherosclerosis and aortoiliac occlusive disease are often encountered concomitantly. The authors report a technique of combined brachiocephalic and femoral revascularization in which a single transthoracic approach is used.

Arterial occlusions and stenoses that involve multiple brachiocephalic arteries produce variable combinations of cerebral, brain stem, and upper-extremity ischemic symptoms. The complexity of these lesions often requires direct transthoracic reconstruction because proximal involvement of all the brachiocephalic trunks precludes extrathoracic cervical reconstruction. ^1–5

Concomitant lower-limb ischemia and cerebrovascular disease are frequent findings. Surgical treatment in these cases is usually performed using a staged approach. ² We report a technique of simultaneous revascularization of the brachiocephalic and femoral vessels.

Case Report

In June 1998, a 51-year-old man presented for disabling bilateral intermittent claudication. He also complained of severe vertigo, syncope, and bilateral visual disturbances upon extension or rotation of the neck. He was a heavy cigarette smoker and was known to have a history of combined dyslipidemia. Physical examination showed absence of peripheral pulses in both upper and lower limbs, as well as a right cervical bruit. Blood pressure measured in the upper limbs was 90/60 mmHg. The rest of the examination was normal.

Ultrasonic duplex scanning showed total occlusion of the right subclavian artery (RSCA), the left common carotid artery (LCCA), and the left subclavian artery (LSCA). There was inversion of flow in both right and left vertebral arteries, which caused a bilateral subclavian steal syndrome. The right common carotid artery (RCCA) was patent, with no significant stenosis on either the right internal or the external branches.

Aortography confirmed the findings of the duplex scan by showing 1) total occlusion of the RSCA with retrograde flow through the right vertebral artery, 2) an infiltrated RCCA with no noteworthy stenosis, 3) total occlusion of the LCCA extending to the intracranial segment of the internal carotid, and 4) total occlusion of the LSCA with retrograde flow through the left vertebral artery. Intracranial circulation was dependent on the right internal carotid flow. The right external carotid artery revascularized the left external carotid artery through collateral vessels, particularly through its upper thyroid branch.

A coronary angiogram showed normal coronary arteries, together with normal left ventricular function. An aortogram showed severe aortoiliac occlusive disease, with near occlusion of the aortic bifurcation and total occlusion of both common iliac arteries. The femoropopliteal arteries were patent, without significant stenosis. A computed tomographic scan of the brain was normal.

Concomitant revascularization of the cerebral and femoral arteries was decided upon. Through a median sternotomy, the aortic arch and its branches were dissected and controlled.

1. After placing a side-biting clamp, we anastomosed a 14- × 7-mm bifurcated Dacron tube to the ascending aorta.

2. The right branch of the Dacron prosthesis was then anastomosed to the RSCA, at a point 2 cm distal to its origin.

3. The left branch was anastomosed to the LSCA, which we approached through a separate supraclavicular incision.

4. We dissected the left carotid bifurcation via a separate incision in order to explore both the distal internal and external carotid arteries, with the thought of revascularizing one of them with a vein graft anastomosed to the Dacron prosthesis. The internal carotid artery was found to be totally occluded and fibrotic, whereas the external carotid had a large caliber and displayed a normal pulse. Therefore, grafting of this vessel was judged unnecessary.

5. A polytetrafluoroethylene (PTFE) graft was then anastomosed to the inferior aspect of the body of the Dacron tube and was directed into the right pleural cavity, reaching the costophrenic sulcus. It was then tunneled through the diaphragmatic insertions into the retroperitoneal space that lies medial to the muscles of the abdominal wall (that is, the entire route was extraperitoneal). We next made a lateral flank incision at the level of the right iliac crest, through the abdominal muscles to the level of the peritoneum, without entering the peritoneum. Here we made another extraperitoneal tunnel, through which we pulled the PTFE prosthesis and directed it distally under the inguinal ligament to the left common femoral artery.

6. A femoro–femoral bypass was then performed, using a standard technique. On day 5, control angiography showed patency of both the brachiocephalic and femoral grafts (Figs. 1 and 2)

Fig. 1 Top image: Control angiogram shows perfect patency of the Y graft from the ascending aorta to both the right and left subclavian arteries. Bottom image: The polytetrafluoroethylene (PTFE) graft that leads from the Dacron graft to the right and left femoral arteries is also patent.

Fig. 2 Schematic drawing of the operative technique.

The postoperative course was uneventful.

Commentary

Operative treatment of subclavian steal syndrome can be performed using various surgical techniques, including reimplantation of the subclavian artery into the carotid in an end-to-side fashion, carotid-to-subclavian bypass, subclavian-to-subclavian bypass (cross-over), femoro–axillary bypass (retrograde), and aortosubclavian bypass (transthoracic). ^1–8

Our patient presented with bilateral total occlusion of both subclavian arteries, as well as of the left common carotid artery. He also had bilateral occlusion of both iliac arteries. Therefore, the anatomic presentation precluded all of the above-mentioned revascularization techniques except for the aortosubclavian bypass, which offered the possibility to perform simultaneous bilateral revascularization of both subclavian arteries, as well as of the left carotid artery branches.

Aortoiliac occlusive disease is often associated with cerebrovascular disease. These 2 conditions are usually treated separately by means of a staged approach. ² Our patient had disabling neurologic symptoms in association with severe bilateral brachiocephalic atherosclerosis, which precluded primary aortoiliac reconstruction. Concomitantly, he had disabling pain in both lower limbs, due to severe aortoiliac occlusive disease.

Because a median sternotomy was in any event necessary to revascularize the cerebral vessels, we decided to perform a single-stage revascularization of the cerebrovascular axes and the lower limbs by means of an ascending aorta-to-femoral bypass. We have previously reported excellent short- and long-term results with this operation. ⁸ Moreover, it is simple to perform and avoids a 2nd procedure that would require an additional abdominal incision, extra costs, and longer recovery time.