Direct subclavian—carotid anastomosis for the subclavian steal syndrome

Between 1984 and 1986, 38 patients—25 males and 13 females—underwent treatment for proximal Subclavian arteriosclerotic lesions. All of these patients presented with symptoms of the Subclavian steal syndrome and 13 (34.2%) had additional claudication of the arm. Preoperative angiography showed distal filling of the subclavian artery via retrograde flow in the vertebral artery. 31 patients (81.5%) had total occlusion of the proximal subclavian artery and 7 (18.5%) presented with severe stenosis. 34 of these lesions were on the left (89.5%) and 4 on the right side (10.5%). Complete cerebral angiography was performed in each patient with emphasis on visualisation of the carotid bifurcation and selective opacification of the aortic arch vessels if indicated. Doppler ultrasound flow measurement in the vertebral artery yielded the basic data which were then used for comparative postoperative evaluation. The operation was performed under general anaesthesia and heparinisation. A shunt was not required while performing the direct end-to-side anastomosis between the transected subclavian and the common carotid artery. Arteriosclerotic plaques in the distal stump of the transected subclavian artery and occasionally the origin of the vertebral artery were dealt with by simple eversion endarterectomy. There was no operative mortality; the postoperative complication rate was 13.1% including palsy of the recurrent nerve in 3 patients, a lymphatic cyst of the neck in one patient and bleeding requiring re-exploration in another. Occlusion of the reconstructed artery or neurologic deficit did not occur. Post operatively all patients were treated with platelet inhibitors. The average follow-up period was 13 months, when the reconstructed arteries were found to be patent in 37 patients (97.4%). In all patients, relief of the previously existing symptoms of the subclavian steal syndrome and arm claudication occurred. The 1-year results of this procedure are very satisfactory and in our department subclavian carotid transposition has therefore become the method of choice in the surgical treatment of the subclavian steal syndrome.