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Subclavian Artery Revascularization - A Changing Practise
Peter Naughton, MD, Manuel Garcia-Toca, Heron Rodriguez, MD, Mark Eskandari, MD, Mark Morasch, MD.
Northwestern Memorial Hospital, Chicago, IL, USA.

Introduction
Surgical revascularization for occlusive and aneurysmal disease of the subclavian artery is a challenging but rarely performed procedure. Over the last ten years the emergence of endovascular aortic repair (TEVAR) and the introduction of endovascular intervention for subclavian lesions have impacted on the indications and techniques for subclavian artery revascularization. We report an eleven year single-center experience of subclavian artery intervention.
Methods
Eighty patients underwent subclavian artery revascularization between January 1999 and December 2009. Median age was 61 years (range 16-87 years) and 44 were male. Indication for intervention included lengthening proximal landing zone for TEVAR (n=37), upper limb ischemia (n=13), vertebro-basilar disease (n=11), subclavian artery aneurysm (n=12), subclavian steal (n=9), trauma (n=6) and miscellaneous (n=7).
Results
Sixty-five cases (81%) were performed electively. Revascularization was achieved by open repair in 71 patients including carotid transposition (n=46) and carotid to subclavian bypass (n=22). Nine patients underwent endovascular reintervention with balloon-expandable stent (n=6), self-expanding stent (n=1), stent-graft (n=1) and angioplasty (n=1). Of patients who underwent TEVAR, 86 % of patients had subclavian revascularization performed prior to deployment of stent-graft. Complications included stroke (n=2), recurrent laryngeal nerve palsy (n=2), Horners (n=2) and neck hematoma (n=2). There were no 30 day mortalities. In two TEVAR patients the stent-graft occluded the origin of the left common carotid artery, additional stents were deployed to salvage cerebral perfusion. Median follow-up was 41 months.
Conclusion
The techniques and indications for subclavian artery revascularization are evolving. Desirable outcome can be achieved with appropriate technical expertise and careful patient selection.


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