Intrathoracic Approach for Subclavian and Innominate Artery Reconstruction

Abstract

A subclavian or innominate artery obliteration may cause a retrograde flow in the vertebral artery, a subclavian steal. The steal has been associated with cerebral symptoms indicating vertebrobasilar ischaemia, the subclavian steal syndrome. As there still are no objective means of measuring the effect of the steal on the brain circulation, the syndrome can only be proved by experience from the results of surgical attempts to correct the steal. The steal was at first eliminated by direct reconstruction of the subclavian and innominate arteries through a thoracic approach. As the mortality was high, many surgeons have used cervical bypass procedures with considerably lower mortality. The present report is based on 15 years' experience with 85 patients operated on with direct artery reconstruction through a thoracotomy. A low mortality (1.3%) for the last ten years, a high patency of the reconstruction (80%) 8 years postoperatively and a rather high rate of improvement (72%) in patients with subclavian steal syndrome were found. The study shows that the mortality rate with the thoracic approach need not necessarily be higher than with the cervical one. The high patency and the haemodynamically correct type of the reconstructions favour the thoracic approach. However, the direct reconstruction demands a technically advanced surgeon. who is well aquainted with the method. The results also showed that surgery still may be an alternative in patients with symptomatic subclavian steal.