|Year : 2019 | Volume
| Issue : 1 | Page : 33-36
Subclavian carotid transposition: A single-center experience
Hemachandren Munuswamy1, Duvuru Ram2, Sreevathsa Prasad1, Suresh Kumar Rajan1, Durgaprasad Rath1, Bathal Vedagiri Saichandran1
1 Department of CTVS, JIPMER, Puducherry, India
2 Department of CTVS, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry, India
|Date of Web Publication||8-Mar-2019|
Dr. Duvuru Ram
Department of CTVS, Mahatma Gandhi Medical College and Research Institute, SBV University, Puducherry
Source of Support: None, Conflict of Interest: None
Objective: Subclavian carotid transposition (SCT) is generally performed for stenoocclusive disease of the proximal subclavian artery. This study was undertaken to analyze the results of SCT at our center and also highlight the usefulness of this procedure in varied pathologies involving the proximal subclavian artery. Patients and Methods: This retrospective study included 16 consecutive patients from 2011 to 2016 who presented to our department. The study was carried following approval by the Institute Research Committee and the Institute Ethics Committee. The data were collected from the departmental database, and the patients were followed up prospectively and the data were analyzed. Results: The mean age of the patients at presentation was 46.6 years with standard deviation of 11.48. Eleven patients (78%) had total occlusion of the proximal subclavian artery. About 81% of the patients had left-sided SCT. The etiology for SCT was varied with ten patients (62.5%) having proximal subclavian artery occlusion with chronic upper-limb ischemia, three patients (18.75%) with acute subclavian artery occlusion, one patient with bilateral cervical ribs, one patient with dysphagia lusoria with aberrant right subclavian artery (ARSA), and one patient with right common carotid aneurysm. The mean follow-up duration was 64 months. The patency rate was 100% in the study population. There were no immediate occlusions or stenosis noted in our series. Conclusion: SCT is a safe, effective, and durable procedure with long-term patency rates with less morbidity and reintervention rates. It can be safely done for both acute and chronic subclavian artery occlusions and various other conditions too such as dysphagia lusoria due to ARSA and cervical rib with subclavian artery occlusion. Hence, a vascular surgeon should master the art of doing SCT for its good results and for its being effective for varied pathologies.
Keywords: Outcome of subclavian carotid transposition, proximal subclavian artery pathology, subclavian carotid transposition
|How to cite this article:|
Munuswamy H, Ram D, Prasad S, Rajan SK, Rath D, Saichandran BV. Subclavian carotid transposition: A single-center experience. Indian J Vasc Endovasc Surg 2019;6:33-6
|How to cite this URL:|
Munuswamy H, Ram D, Prasad S, Rajan SK, Rath D, Saichandran BV. Subclavian carotid transposition: A single-center experience. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jul 15];6:33-6. Available from: http://www.indjvascsurg.org/text.asp?2019/6/1/33/253740
| Introduction|| |
Subclavian carotid transposition (SCT) was first described by Parrott in 1964. SCT is generally performed for the stenoocclusive disease of the proximal subclavian artery. Open procedures include SCT, carotico-subclavian bypass, subclavian to subclavian bypass, and axilloaxillary bypass. Of all these procedures, SCT is the most effective away of addressing the pathology in that it avoids graft and its associated complications and the diseased segment is excluded., Endovascular approaches include angioplasty, stenting, or both. The recurrence rates are high with angioplasty, and hence, stenting has been combined with angioplasty. The present study was undertaken to analyze the results of SCT at our institution and also to show the various other pathologies apart from chronic subclavian artery occlusions where SCT can be effective.
| Patients and Methods|| |
This study was a hospital-based retrospective analysis of patients who underwent SCT in the Department of Cardiothoracic and Vascular Surgery. The study included all patients who underwent SCT between 2011 and 2016. The study was done with the approval of the Institute Research Committee and the Institute Ethics Committee. The data were collected from the departmental database, and the patients were followed up prospectively. Baseline demographic data, etiology, symptomatology, intraoperative findings, postoperative complications, and follow-up data were analyzed. Continuous variables were summarized as mean and categorical variables were expressed as frequency and percentage.
Preoperatively, apart from routine blood investigations, contrast-enhanced computerized tomography of the upper limbs and arch vessels with angiography of the brain was included to ascertain the completeness of the circle of Willis. Through a supraclavicular incision, the subplatysmal flap was raised, and the sternocleidomastoid muscle was dissected. The clavicular head of sternocleidomastoid muscle was divided close the periosteum unlike that described by Morasch, where the dissection of subclavian artery is between the heads of the sternocleidomastoid sparing it. Carotid sheath was dissected to mobilize the internal jugular vein and carotid artery. Omohyoid was retracted or divided [Figure 1]. The scalenus anticus muscle was isolated. Phrenic nerve was secured. Subclavian artery with its branches – the vertebral, internal mammary, and thyrocervical trunk – were dissected and mobilized. Before dividing the subclavian artery, the carotid was clamped, and the distal pressure was monitored, and only if a mean of 50 mmHg is maintained, anastomoses was initiated. Otherwise if needed, noradrenaline was started to maintain a mean of at least 50 mmHg distal to clamp. We did not use any shunt after opening carotid artery, as the mean arterial pressure of the carotid artery distal to the clamp is always kept more than 50 mmHg. Subclavian artery was divided between clamps usually proximal to the vertebral artery. In rare case scenario wherein there is disease progression to the second part of subclavian like in acute or acute on chronic upper-limb ischemia, the vertebral artery was also divided. After taking running sutures over the proximal stump, end-to-side anastomosis was done with the common carotid artery. On the left side, thoracic duct and lymphatic branches were ligated during dissection. Wound was closed in layers leaving a drain.
|Figure 1: Intraoperative image of subclavian carotid transposition. (SCM: Sternocleidomastoid, Omo: Omohyoid, C: Carotid artery, Sc: Subclavian artery, IJV: Internal jugular vein)|
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In a case with aberrant right subclavian artery (ARSA), ARSA was approached through right supraclavicular incision, clavicular head of sternomastoid was divided, and ARSA was divided as much close to the origin as possible. A mediastinoscope is suggested to be useful in ligating ARSA closer to the origin, but in our case, it was not used [Figure 2].
|Figure 2: Computed tomography image and intraoperative image of the aberrant right subclavian artery (R SCA: Right Subclavian artery, TCt: Thyrocervical trunk, Vt: Vertebral artery)|
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| Results|| |
A total of 16 patients were operated during the study period. There was a predilection toward male gender with 12 of the patients (75%) being males. The mean age of the patients at presentation was 46.6 years with a standard deviation of 11.48. Eighty-one percent of the patients had left-sided SCT. Seventy-eight percent of the patients presented with total occlusion of the proximal subclavian artery. Smoking and alcohol were associated with ten patients. Three patients had diabetes mellitus, and eight patients were hypertensive [Table 1].
The etiology for SCT was varied with ten patients (62.5%) having proximal subclavian artery occlusion with chronic upper-limb ischemia, three patients (18.75%) presented with acute subclavian artery occlusion, one patient (6%) had bilateral cervical ribs with occlusion of the proximal subclavian artery on the left side, one patient (6%) had dysphagia lusoria with ARSA, and one patient (6%) presented with right common carotid aneurysm. Fifty percent of the patients presented with claudication pain. Five patients presented with paresthesias, and two patients each had vertigo and visual disturbances. None of our patients had the coexisting cerebrovascular disease [Table 2].
The patency rate was 100% on follow-up at postoperative day 30 as well as on regular outpatient department (OPD) visits thereafter in the study population. There were no immediate occlusions or stenosis noted in our series. Patients were evaluated by duplex imaging on the postoperative day30 and were followed up by clinical examination on subsequent OPD visits. The mean follow-up duration was 64 months. One patient had chylous drain on the left side, whereas one patient had brachial plexopathy causing paresthesia which resolved over 3 months as a complication of cervical rib and one patient had wound-related complication. None of the patients in our series had bleeding or stroke as a complication. There were no symptoms related to carotid clamping [Table 3].
Early and long-term results
Thirty-day patency and long-term patency were 100%. There was no 30-day mortality in the present series. Three patients had digit gangrene preoperatively which required digital amputation. Symptomatic improvement was noted in all patients in the present series.
| Discussion|| |
We performed SCT as the procedure of choice for proximal subclavian artery disease. SCT can be technically challenging. In our study, SCT was found effective for other disease conditions as well including acute subclavian artery occlusions.
There are many advantages of SCT over carotid-subclavian bypass. SCT provides prograde flow thereby providing superior hemodynamics. The proximal segment of subclavian artery is ligated in SCT, whereas a blind segment remains in bypass procedure which may serve as a nidus for thrombus formation. Prosthetic graft is not required in SCT unlike in carotid-subclavian bypass with obvious advantages.,,
SCT for proximal subclavian artery occlusions is well known. Although endovascular approach is gaining popularity to treat such lesions, the success rate in terms of long-term patency and reintervention rates is better with SCT than with endovascular approach. More so, when complete occlusion of subclavian artery is taken into consideration, the patency rates and reintervention rates are always better with SCT. In our study, 78% of the patients had complete occlusion of the proximal subclavian artery, and SCT is proven to be a good modality of treating this subset of patients as there was no morbidity and mortality with nil reintervention rates in the 1st month and 100% long-term patency rates.
The perioperative incidence of stroke has been reported. In our study, none of the patients developed stroke perioperatively. It may be attributed to the absence of carotid disease in our patient subset and also due to careful selection of patients by doing contrast-enhanced computed tomography brain to ascertain completeness of circle of Willis and maintaining post clamp carotid pressure mean 50 mmHg under anesthesia. All the patients in our study population had completeness of the circle of Willis.
Local wound complication includes wound swelling due to hematoma which was evacuated under local anesthesia for one patient, and other patient had increased chylous drain output which was conservatively managed with fat-free diet and retaining the drain for 10 days.
SCT was also found effective in treating patients presenting with acute limb ischemia. There is no published literature supporting SCT for acute occlusions of the proximal subclavian artery. In patients with acute presentations, same steps were followed except that after dividing the subclavian artery and suture ligating the stump, embolectomy is done for the distal part and after establishing a good backflow, SCT is performed. For acute occlusions also, there was no morbidity and mortality in the present study, and patients had immediate recovery with respect to the symptoms.
SCT was also done for a patient with dysphagia lusoria who was diagnosed to have ARSA compressing the esophagus after extensive work up. A patient had uneventful recovery after SCT, and the patient did not have any complaints of dysphagia on follow-up.
The authors also found SCT as one viable option in reestablishing the circulation to left upper limb in a patient with symptomatic cervical rib with proximal subclavian artery occlusion. This patient had brachial plexopathy probably due to cervical rib excision.
Even in this endovascular era, where more studies have shown good results for stenting of proximal subclavian artery lesions, SCT has its place for subclavian artery occlusive disease as well as for many other conditions discussed in the study population.
| Conclusion|| |
SCT is safe, effective, and durable procedure with long-term patency rates with less morbidity and reintervention rates. It can be safely done for both acute and chronic subclavian artery occlusions and various other conditions too like dysphagia lusoria due to ARSA and cervical rib with subclavian artery occlusion. Hence, a vascular surgeon should master the art of doing SCT for its good results and for its being effective for varied pathologies.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Parrott JC. The subclavian steal syndrome. Arch Surg 1964;88:661-5.
Duran M, Grotemeyer D, Danch MA, Grabitz K, Schelzig H, Sagban TA. Subclavian carotid transposition: Immediate and long-term outcomes of 126 surgical reconstructions. Ann Vasc Surg 2015;29:397-403.
Cinà CS, Safar HA, Laganà A, Arena G, Clase CM. Subclavian carotid transposition and bypass grafting: Consecutive cohort study and systematic review. J Vasc Surg 2002;35:422-9.
Song L, Zhang J, Li J, Gu Y, Yu H, Chen B, et al.
Endovascular stenting vs. extrathoracic surgical bypass for symptomatic subclavian steal syndrome. J Endovasc Ther 2012;19:44-51.
Morasch MD. Technique for subclavian to carotid transposition, tips, and tricks. J Vasc Surg 2009;49:251-4.
Fukuhara S, Patton B, Yun J, Bernik T. A novel method for the treatment of dysphagia lusoria due to aberrant right subclavian artery. Interact Cardiovasc Thorac Surg 2013;16:408-10.
Diethrich EB, Garrett HE, Ameriso J, Crawford ES, el-Bayar M, De Bakey ME. Occlusive disease of the common carotid and subclavian arteries treated by carotid-subclavian bypass. Analysis of 125 cases. Am J Surg 1967;114:800-8.
Schardey HM, Meyer G, Rau HG, Gradl G, Jauch KW, Lauterjung L. Subclavian carotid transposition: An analysis of a clinical series and a review of the literature. Eur J Vasc Endovasc Surg 1996;12:431-6.
Linni K, Ugurluoglu A, Mader N, Hitzl W, Magometschnigg H, Hölzenbein TJ. Endovascular management versus surgery for proximal subclavian artery lesions. Ann Vasc Surg 2008;22:769-75.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]