Abstract

ABSTRACTThis study reviews the spectrum of clinical presentations and methods of treatment used in 35 patients with subclavian or innominate occlusions over the past 16 years. Symptoms included vertigo or dizziness, visual disturbances, and lateralizing hemispheric symptoms. Twenty-two patients had arm claudication or weakness, and 88% had a difference in bilateral arm blood pressures (range, 10–180 mm Hg). The sites of occlusion included the left subclavian (29 patients), the right subclavian (four patients), and the innominate (three patients). One patient had bilateral disease. Although 86% had angiographic evidence of reversal of flow in the vertebral artery, only two patients had the classic symptoms of arm-exercise-induced cerebral ischemia. Operations included transthoracic endarterectomy (19 patients), carotid-subclavian bypass (11 patients), carotid implantation of the vertebral artery (one), axillo-axillary bypass (three), and subclavian-subclavian bypass (one). Four patients had simultaneous carotid bifurcation endarterectomies. The single postoperative death followed an innominate endarterectomy. Two of four graft failures were later retrieved by reoperation. A beneficial response to operation was seen in 94% of the surviving patients. Although the clinical presentations varied, bilateral blood pressure recordings were useful in screening. Whereas angiography commonly shows an “anatomic subclavian steal,” the classic symptoms of this syndrome are rare. Finally, this series reviews the evolution of operative technics used for these lesions and underscores the role of extra-anatomic repair in limiting the risk of their management.