Ann Thorac Surg 1999;67:657-660
© 1999 The Society of Thoracic Surgeons
Original Articles
Common brachiocephalic trunk: strategies for revascularization
Anthony Azakie, MDa,
Doff B. McElhinney, MDa,
Louis M. Messina, MDa,
Ronald J. Stoney, MDa
a Division of Vascular Surgery, University of California, San Francisco, San Francisco, California, USA
Accepted for publication August 5, 1998.
Address reprint requests to Dr Stoney, Division of Vascular Surgery, UCSF, 505 Parnassus Ave, M488, San Francisco, CA 94143-0222
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Abstract
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Background. A common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is a normal variant of aortic arch branching that occurs in approximately 10% of the population. Because three of the four primary sources of cerebral blood flow arise from a single aortic branch, stenosis or occlusion of a common trunk can cause severe ischemic consequences. Common trunk revascularization has been described, but there have been no reports focusing on the management options for occlusive disease of this vascular anatomy.
Methods. A retrospective review of our experience with innominate artery revascularization identified 6 patients who underwent revascularization of a common brachiocephalic trunk between 1977 and 1997. All patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n = 3) caused by atherosclerosis (n = 5) or Takayasu’s arteritis (n = 1). Revascularization was achieved by a prosthetic bypass graft from the ascending aorta to the innominate or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n = 1). Concomitant endarterectomy of branch vessels was performed in 3 patients.
Results. There was one perioperative death from myocardial infarction, and one perioperative stroke, with death occurring 1 month after hospital discharge. One patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy that resolved without sequelae with antihypertensive medications. During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years after operation. All surviving patients are alive and free from symptomatic recurrence.
Conclusions. Revascularization for occlusive disease of a common brachiocephalic trunk can be achieved with effective and durable relief of symptoms using either a prosthetic bypass graft or endarterectomy. However, neurologic complications in 2 patients, which were fatal in 1, attest to the potential cerebral ischemic threat posed by occlusive disease of a common brachiocephalic trunk.
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Introduction
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A common brachiocephalic trunk is a variant of aortic arch development in which both common carotid arteries and the right subclavian artery originate from a single trunk that arises from the arch. In both autopsy studies and large surgical series of innominate artery disease, a common trunk has been found to occur in up to 10% of the population [1, 2]. It is considered a normal variant of arch branching, inasmuch as it is not typically associated with structural congenital cardiovascular disease. Nevertheless, a common trunk can pose significant problems if it becomes obstructed because it supplies three of the four primary sources of cerebral blood flow. Common trunk reconstruction for occlusive disease has been described infrequently in series of patients with innominate artery disease [2]. Moreover, there have been no reports of the surgical management of this condition, which differs in several important respects from occlusive disease of the innominate artery. The standard approaches to revascularization of a stenotic or occluded innominate artery are transinnominate endarterectomy or a prosthetic bypass graft from the ascending aorta to the brachiocephalic branch vessels [2–4]. These strategies can both be used safely in patients with a diseased common trunk as well. In the present report, we describe our experience with revascularization in 6 patients with common brachiocephalic trunk.
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Patients and methods
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Patients
Between 1977 and 1997, 64 patients underwent revascularization for innominate artery occlusive disease. Six of these patients had a common brachiocephalic trunk. All were women who ranged in age from 33 to 66 years. Five patients had a combination of neurologic and right upper extremity symptoms; the remaining patient had a history of transient ischemic attacks without upper extremity symptoms. All patients had at least one risk factor for arterial occlusive disease, including cigarette smoking (n = 4), systemic hypertension (n = 1), and Takayasu’s arteritis (n = 1). One patient had undergone previous cerebrovascular intervention—a right bifurcation carotid endarterectomy. All patients underwent preoperative arch aortography, which showed complete occlusion in 3 patients and severe stenosis in 3. Associated arch vessel disease was present in 4 patients, including stenosis or occlusion of the right common carotid (n = 2), right subclavian (n = 1), right vertebral (n = 1), left common carotid (n = 2), left subclavian (n = 3), and left vertebral (n = 1) arteries. One of the patients with complete occlusion of the common trunk also had complete occlusion of the left vertebral artery, and all cerebral blood flow was through collateral channels. Aside from the common brachiocephalic trunk, arch anatomy and branching patterns were normal in all patients but 1, in whom the left vertebral artery originated from the arch directly, between the common trunk and left subclavian artery (Fig 1). Patient data are summarized in Table 1.
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Fig 1. Preoperative ascending aortogram from a patient with complete occlusion of a common brachiocephalic trunk who subsequently underwent successful endarterectomy. (A) This image from the early phase demonstrates complete occlusion of the first brachiocephalic vessel (common trunk). There is some filling of the innominate and right subclavian arteries through collateral channels. The left vertebral artery arises directly from the arch, immediately proximal to the left subclavian artery, which is stenotic as well. The sole source of flow to the cerebral circulation, other than through collateral channels, is the left vertebral artery. (B) Late-phase image from the same aortogram demonstrates delayed filling of the right vertebral artery through collateral channels and collateral channels to the cranial circulation. The calcific plaque occluding the common trunk can be appreciated more clearly with retrograde filling of the distal common trunk.
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Table 1. Characteristics of Patients Undergoing Revascularization for Occlusive Disease of a Common Brachiocephalic Trunk
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Operative procedures
All patients underwent a median sternotomy that was extended into the right supraclavicular region to optimize exposure of the innominate bifurcation. The ascending aorta, arch, and proximal brachiocephalic vessels were exposed circumferentially and evaluated to assess the proximal and distal extension of disease.
In 5 patients, a prosthetic bypass graft from the ascending aorta was used. In 3 of these patients, a bifurcated graft was anastomosed into both the innominate and left common carotid arteries. In the other 2 patients who underwent prosthetic bypass grafting, a single-limbed graft was anastomosed distally to the common trunk or the innominate artery. In 1 of these patients, the left common carotid artery arose from the common trunk beyond the stenosis, and a single-limbed graft was sufficient to revascularize all branches. In the other patient, significant occlusive disease began beyond the origin of the left common carotid artery. The innominate artery was divided beyond the origin of the left carotid artery, and the proximal innominate artery was oversewn, ensuring perfusion of the left carotid artery from the patent origin of the common trunk while allowing perfusion of the innominate branch vessels through the tube graft. In 2 of these patients, extraction endarterectomy of the right subclavian and common carotid arteries was performed before the distal graft anastomosis at the innominate bifurcation was done. Dacron grafts ranging from 6 to 8 mm in diameter were used.
In the sixth patient, who had complete occlusion and a heavily calcified plaque extending from the origin of the common trunk to the bifurcation into the right subclavian and common carotid arteries and into the left common carotid artery, revascularization was achieved by endarterectomy. Becuase the common trunk was completely occluded, clamping of its origin would not further compromise cerebral perfusion, so it was decided to perform endarterectomy rather than bypass grafting. A Wylie J clamp was applied to the transverse arch to isolate the origin of the common trunk. A transverse arteriotomy was centered just proximal to the origin of the left common carotid artery in the common trunk, as opposed to the standard longitudinal arteriotomy used for innominate endarterectomy [5]. Extraction endarterectomy was performed with good end points in the left and right common carotid arteries and the right subclavian artery. The calcified plaque was then removed from the proximal common trunk and dome of the transverse arch. Flow was restored to the right subclavian and both common carotid arteries after 60 minutes of clamp time. Intraoperative duplex ultrasound showed normal flow profiles in the common trunk and it branches.
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Results
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One patient with no history or suspicion of cardiac disease died perioperatively of myocardial infarction. Another patient died 1 month after hospital discharge (2 months after operation), after a postoperative stroke. This patient had a completely occluded common trunk and left vertebral artery and had been receiving all cerebral blood flow through collateral channels before revascularization and had symptoms of cerebrovascular insufficiency, transient ischemic attacks, and right arm claudication.
The patient who underwent endarterectomy had an uneventful recovery and was discharged home on the fifth postoperative day. Two days later she developed a severe headache, consistent with the findings of cerebral hyperperfusion. The headache resolved 4 days later with antihypertensive therapy.
During a follow-up period ranging from 1 to 20 years, there was one late death from congestive heart failure 5 years postoperatively. At follow-up of 1, 10, and 20 years, respectively, the 3 surviving patients are alive and well. The patient with Takayasu’s arteritis underwent left common carotid to left subclavian artery bypass grafting for severe subclavian artery stenosis 8 months after common trunk revascularization. No other reoperations have been required, and no patients have demonstrated symptomatic recurrence of disease.
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Comment
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Origin of the left common carotid artery from the innominate artery is a variant of aortic arch branching that occurs in approximately 10% of humans but is the usual configuration in some animal species [1, 2]. Although not typically associated with other structural anomalies of the cardiovascular system, a diseased common brachiocephalic trunk can have major ischemic implications, given that it supplies both carotid arteries and the right vertebral and subclavian arteries. Although a common trunk is present in a significant proportion of the population, symptomatic occlusive disease is rare. Stenosis or occlusion of a common trunk requiring operation has been reported in fewer than 25 patients, all of whom were included in series of innominate artery reconstruction [2–4]. In a series of 134 patients with innominate artery occlusive disease, Kieffer and associates [2] found 13 patients with a common trunk (10%). The technique of repair in these patients was not specified, but because bypass grafting was used in nearly 80% of the entire series it was most likely used in these patients as well. Cherry and colleagues [3] suggested that prosthetic bypass grafting be used in patients with symptomatic occlusive disease of a common trunk, but they did not describe their own experience. We are not aware of any reports that focus on the management of this problem.
Since 1977, we have operated on 6 patients with stenosis or occlusion of a common trunk. Prosthetic bypass grafting was performed in 5 of these patients and endarterectomy in the other. Both techniques have yielded effective and durable relief of symptoms. In our series of 99 patients undergoing innominate artery revascularization with endarterectomy (n = 72), prosthetic bypass grafting (n = 22), or balloon angioplasty (n = 5) since 1960, the actuarial survival rate at 1 year was 96% [6]. Although the small size of the present series precludes meaningful statistical comparison with the cohort of patients undergoing innominate revascularization, we suspect that a common trunk places patients at higher risk for adverse postoperative outcome.
The choice of revascularization procedure will depend on the particular anatomy, hemodynamic variables, and arterial pathologic features in a given patient. Endarterectomy requires proximal control, with an exclusion vascular clamp used to isolate the aortic origin of the brachiocephalic vessel. Exclusion of flow through a patent but diseased common trunk will interrupt antegrade flow into both common carotid arteries and the right vertebral artery, which can produce significant brain ischemia. However, with complete occlusion of the common trunk, application of the exclusion clamp will not affect cerebral blood flow and provides optimal circumstances for common trunk endarterectomy. Critical stenosis of the common trunk with adequate collateral circulation may allow temporary common trunk exclusion for endarterectomy, which can be assessed by measuring left and right carotid stump pressures. If uncertainty exists regarding the adequacy of collateral flow, prosthetic bypass grafting is advised. Bypass grafting allows for sequential revascularization of the right and left common carotid systems and does not require any period of total occlusion of the common trunk. When occlusive disease extends distal to the anastomotic site, extraction endarterectomy can be performed readily to ensure optimal durability of the bypass graft.
In patients with occlusion or critical stenosis of the common trunk, significant reduction in pressure and flow through the anterior cerebral circulation may evoke symptoms of cerebral hypoperfusion and lead to impairment of cerebrovascular autoregulation. Revascularization of the ischemic territory results in acutely increased pressure and flow, which sometimes causes severe ipsilateral headache and occasionally seizures, along with radiologic evidence of cerebral edema [7]. Postoperative cerebral hyperperfusion is thought to be a consequence of impaired cerebral vascular autoregulation [8] and typically occurs in patients who undergo repair of high-grade occlusive lesions of the extracranial arteries. Although this syndrome is observed most often after carotid endarterectomy [7, 8], it has been reported after innominate artery reconstruction as well [9]. In one of our patients with preoperative symptomatic cerebral ischemia caused by complete occlusion of the common brachiocephalic trunk, endarterectomy restored full flow through the anterior cerebral circulation bilaterally, and she developed a severe headache of 4 days in duration beginning on the seventh postoperative day. The symptoms resolved with antihypertensive therapy, and she remains asymptomatic 1 year later.
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References
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Edwards J.E. An atlas of acquired diseases of the heart and great vessels. New York: WB Saunders, 1961.
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Kieffer E., Sabatier J., Koskas F., Bahnini A. Atherosclerotic innominate artery occlusive disease: early and long-term results of surgical reconstruction. J Vasc Surg 1995;21:326-337.[Medline]
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Carlson R.E., Ehrenfeld W.K., Stoney R.J., Wylie E.J. Innominate artery endarterectomy: a 16-year experience. Arch Surg 1977;112:1389-1393.[Abstract]
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Azakie A., McElhinney D.B., Higashima R., Messina L.M., Stoney R.J. Innominate artery reconstruction: over 3 decades of experience. Ann Surg 1998;228:402-410.[Medline]
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Reigel M.M., Hollier L.H., Sundt T.M., Piepgras D.G., Sharbrough F.W., Cherry K.J. Cerebral hyperperfusion syndrome: a cause of neurologic dysfunction after carotid endarterectomy. J Vasc Surg 1987;5:628-634.[Medline]
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Jorgensen L.G., Schroeder T.V. Defective cerebrovascular autoregulation after carotid endarterectomy. Eur J Vasc Surg 1993;7:370-379.[Medline]
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Abstract
Introduction
