Optimal method of reconstruction in patients with pathology of the 1^st segment of the subclavian artery

Vachev A.N., Dmitriev O.V., Golovin E.A., Stepanov M.Yu.

Clinic and Chair of Faculty Surgery, Samara State Medical University of the RF Ministry of Public Health, Samara, Russia

The study enrolled a total of 318 patients presenting with lesions of the 1^st segment of the subclavian artery and the clinical course of vertebrobasilar insufficiency. All patients prior to admission had been receiving the best course of medicamentous therapy under the supervision of a neurologist for more than 6 months but with no significant clinical improvement. According to the type of the reconstructive operation on the 1^st segment of the subclavian artery, all patients were subdivided into three groups. Group I included 48 (15.1%) patients presenting with occlusion of the subclavian artery and undergoing carotid subclavian bypass grafting. Group II consisted of 224 (70.4%) patients who underwent endarterectomy from the subclavian artery and its transposition to the common carotid artery. Group III was composed of 46 (14.5%) patients presenting with local stenosis of the subclavian artery and subjected to stenting of the 1^st segment of the subclavian artery. The main criteria for assessment of the results were patency of the zone of reconstruction and clinical improvement of the patient after surgery.

Results. Clinical improvement in the early postoperative period was observed in 301 (94%) patients. In Group I, in the early postoperative period, clinical improvement was achieved in 32 (66.7%) patients. Clinical improvement after 3 years persisted only in 16 (33.3%) patients.

In Group II comprising patients with transposition of the subclavian artery to the common carotid artery, clinical improvement was observed in 223 (99.6%) patients. Within 3 years of follow-up, 13 (6.4%) patients were found to have a relapse of the clinical picture of vertebrobasilar insufficiency. Clinical improvement after transposition of the subclavian artery to the common carotid artery at 3 years persisted in 210 (93.6%) patients.

In Group III patients after stenting of the 1^st segment of the subclavian artery in the early postoperative period and during the follow-up period up to 1 year, the angiographic and clinical success amounted to 100%. After 3 years, 8 (17.3%) patients developed relapse of the clinical course because of restenosis, fracture, and thrombosis of the stent. Clinical improvement at 3 years persisted only in 38 (82.6%) patients after stenting.

Comparing the remote results demonstrated that transposition of the subclavian artery to the common carotid artery turned out to be the most justified (p<0.05).

Conclusion. For reconstruction of the 1^st segment of the subclavian artery, an operation of choice is transposition of the subclavian artery to the common carotid artery.

KEY WORDS: steal syndrome, vertebral-subclavian steal syndrome, subclavian artery stenting, 1^st segment of the subclavian artery, transposition of the subclavian artery, subclavian-carotid anastomosis, carotid-subclavian bypass, vertebrobasilar insufficiency.

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Optimal method of reconstruction in patients with pathology of the 1st segment of the subclavian artery

Optimal method of reconstruction in patients with pathology of the 1^st segment of the subclavian artery