Chapter 212: Brachiocephalic Reconstruction
SELECTION OF PATIENTS FOR
DIRECT RECONSTRUCTION OF
THE AORTA
In general, direct reconstruction of the aor-
tic arch branches should be considered in
younger patients with good cardiopulmo-
nary function who have not had a previous
sternotomy. Occlusive disease in a single
branch of the aortic arch rarely warrants
direct reconstruction, whereas multiple le-
sions argue in favor of the transsternal ap-
proach. Lesions that recur following either
percutaneous or extra-anatomic treatment
should be considered for definitive direct
repair. Finally, direct reconstruction is pre-
ferred in cases of multiple branch vessel
disease, particularly if extra-anatomic or
endovascular alternatives are anatomically
impossible due to the absence of an appro-
priate donor vessel, or are unappealing
(e.g., in the presence of open cervical
wounds or tracheostomy) or contraindi-
cated. For example, axilloaxillary bypass
should probably be avoided if a subsequent
sternotomy for coronary disease is likely.
While percutaneous angioplasty and stent-
ing has assumed a prominent role in the
initial management of aortic lesions, there
are a variety of conditions that argue
against percutaneous techniques. For ex-
ample, percutaneous angioplasty of unsta-
ble or mobile innominate lesions that pres-
ent with signs of peripheral
atheroembolism should be undertaken with
caution since angioplasty of these lesions
may be more likely to embolize. The use
of cerebral pro-tection should be strongly
considered in these cases.
In considering patients for direct surgi-cal
reconstruction of the branches of the aortic
arch, there are two significant ques-tions
regarding the natural history of the
obstructive lesion that should be answered:
Does the presence of the lesion increase the
risk of a catastrophic embolic event such as
stroke or limb loss? And, is the lesion asso-
ciated with significant disability? If the an-
swer to these questions is no, then surgical
reconstruction is probably not warranted. An
affirmative answer supports the deci-sion to
consider intervention but does not
differentiate endovascular, extra-anatomic,
and direct surgical options. In general, an
ulcerative lesion in the innominate artery or
either common carotid artery associated with
focal neurologic (stroke, transient ischemic
attack) or ocular (transient mon-ocular
blindness) symptoms should be treated
because of the danger of embolic stroke.
Subclavian or innominate stenotic lesions
that are the source of atheroembo-lism in the
upper extremity should be
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treated due to the risk of limb loss. On the
other hand, the severity of symptoms should
be considered in most cases of sub-clavian,
common carotid, or innominate occlusion
since the symptoms are usually related to
global hypoperfusion rather than
atheroembolism. For example, symptoms
related to arm exertion in cases of subcla-
vian or innominate occlusion may not be
sufficiently debilitating in some elderly pa-
tients to recommend treatment. Similarly,
vertebrobasilar symptoms attributable to
subclavian steal syndrome are not usually the
result of atheroembolism and do not appear
to be associated with an increased risk of
stroke. If vertebrobasilar symptoms are
severe, resulting in a danger of harming
oneself (e.g., falling) or others (e.g., driving),
then treatment should be considered. In some
cases, mild vertebrobasilar symp-toms may
be corrected by simply reducing
antihypertensive medications or treating
transient arrhythmias. Percutaneous an-
gioplasty and stenting or extra-anatomic
reconstruction may be preferable to direct
reconstruction in many patients with sig-
nificant comorbidities.
Obstructive lesions in the innominate,
common carotid, and subclavian arteries are
frequently asymptomatic. In the ab-sence of
symptoms, the presence of high-grade
stenosis or occlusion of one or more branches
of the aortic arch rarely warrants
intervention. Some surgeons have argued that
the same principles that govern the treatment
of asymptomatic carotid artery disease
should be applied to the treatment of
asymptomatic occlusive disease of the aortic
arch branches. Against this argu-ment, the
benefit of carotid endarterec-tomy in patients
with significant (.60%) asymptomatic carotid
stenosis can only be demonstrated if the
operative risk is strin-gently controlled (,3%
perioperative stroke and death) due the fact
that the nat-ural history of carotid stenosis is
relatively benign (11% risk of any ipsilateral
stroke at
5 years). Even with exemplary surgical tech-
nique, at least 20 carotid endarterectomies
must be successfully performed to prevent
one stroke. Unfortunately, little is known
about the natural history of asymptomatic
aortic arch lesions and it is clear that the
surgical treatment is substantially more
complex and associated with greater risk than
simple carotid endarterectomy. In re-cent
surgical reports from both the United States
and France, a small number of as-
ymptomatic patients have been reported. The
decision to undertake direct recon-struction
of asymptomatic lesions of the aortic arch
should be taken with a thor-ough
appreciation of the potential risk of
treatment and the paucity of data that
demonstrates a morbid natural history of
these lesions.
Given these considerations, there are
some situations that clearly warrant treat-
ment of asymptomatic aortic arch branch
Vascular Surgery
lesions. In the setting of tandem lesions at the
carotid bifurcation and at the origin of the
common carotid arteries or the in-nominate
artery, consideration should be given to
simultaneous treatment of both lesions. In
recent years, it has become fash-ionable to
perform retrograde angioplasty and stenting
of the proximal arterial lesion at the time of
open endarterectomy of the more accessible
distal lesion, though the long-term durability
of this strategy re-mains unproven. Another
strategy involves correction of the inflow
lesion with an ex-tra-anatomic reconstruction
such as subclavian–carotid bypass or carotid–
sub-clavian transposition combined with en-
darterectomy of the carotid bifurcation. It is
appealing to perform direct reconstruc-tion of
the aortic arch branch lesion com-bined with
carotid endarterectomy, par-ticularly in the
setting of multiple branch vessel disease
using a variety of bifurcated or branched
bypass grafts. Reconstruction of the aortic
arch branches prior to, or in conjunction
with, internal mammary cor-onary artery
bypass may be appropriate in selected cases.
Rarely, aortic arch branch reconstruction
must be undertaken prior to axillofemoral or
other extra-anatomic grafting. In summary,
treatment of aortic arch branch vessels should
be considered for (a) all arterial lesions that
appear to be the source of atheroembolism to
the arm or cerebral circulation, (b) lesions
that are highly symptomatic by virtue of
global re-duction in cerebral or extremity
blood flow, and (c) occasional asymptomatic
patients.
The decision to perform direct recon-
struction of the branches of the aortic arch
should be based on a thorough history and
physical examination, thoughtful assess-ment
of operative risk factors, appropriate
noninvasive physiologic testing, and pre-cise
vascular imaging. The history should include
attention to the presence of symp-toms
including both lateralizing neurologic
symptoms and nonspecific symptoms such as
instability or weakness. The vascular system
should be thoroughly examined, all
peripheral pulses palpated, bruits and thrills
identified, and both upper extremity blood
pressures recorded. Asymmetry of upper
extremity pulses should be noted. Evidence
of embolism to the fingers should be noted.
Physical examination may reveal a bruit that
radiates to the right side of the sternal notch.
Arch aortography should be