Subclavian carotid transposition and bypass grafting:: Consecutive cohort study and systematic review

Purpose: We describe outcomes in a cohort of patients undergoing subclavian carotid transposition (SCT) for occlusive disease of the first segment of the subclavian artery and perform a systematic review of the literature on SCT and carotid subclavian bypass grafting (CSB). Methods. Relevance, validity and extraction of review results were done in duplicate. Data were collected prospectively in our consecutive cohort of patients. Results. From September 1990 to February 2001, we performed 27 SCTs, four for aneurysmal disease and 23 for occlusive disease. SCTs done for aneurysms were excluded from the current analysis. In patients with occlusive disease, the primary indications for surgery were vertebrobasilar and carotid symptoms (10, 44%), vertebrobasilar insufficiency (7, 30%), vertebrobasilar and arm symptoms (4, 17%), carotid symptoms (1, 4%), and vertebrobasilar, carotid, and arm symptoms (1, 4%). An SCT was performed in conjunction with an endarterectomy of the carotid artery in 12 patients (52%), with an endarterectomy of the subclavian artery in seven patients (30%), and with an endarterectomy of the vertebral artery in six patients (26%). A lymph leak complicated two surgeries (9%). In our series, patients improved clinically after surgery, and reconstructions were all found to be patent by means of Doppler ultrasound scanning at a mean follow-up of 25 +/- 21 months. Three patients (13%) died during follow-up of complications of coronary artery disease. From 1966 to 2000, 516 patients who underwent CSB and 511 patients who underwent a SCT were reported in the literature. Patency rates were 84% and 98%, respectively (P<.0001; absolute risk reduction, 15%; number-needed-to-treat-differently, 7), and the rates of freedom from symptoms were 88% and 99%, respectively, at a mean follow-up of 59 +/- 17 months (range, 1-228 months). Conclusion: Our cohort study showed that SCT is safe and effective for reconstruction of the first segment of the subclavian artery. The systematic review suggested that rates of patency and freedom from clinical symptoms are higher with SCT than with CSB.