title: Brachiocephalic reconstruction I: operative and long-term results for complex disease.
abstract: OBJECTIVE
  Complex brachiocephalic disease involves multiple vessels and is frequently associated with multisystem atherosclerosis. We reviewed surgical outcome and examined the impact of this problem on decision making regarding operative staging, technique, and choice of conduit.
  
  
  METHODS
  Between 1966 and 2000, 157 consecutive patients (mean age, 54.0 years; 48.4% male) with innominate artery or multivessel brachiocephalic disease underwent operative reconstruction using either a transthoracic approach (group A, n = 113) or a less invasive, extrathoracic approach (group B, n = 44). Reconstruction required multiple distal anastomoses in 70 patients (44.6%), concomitant coronary artery bypass grafting (CABG) in 37 patients (23.6%), and concomitant carotid endarterectomy (CEA) in 26 patients (16.6%).
  
  
  RESULTS
  No significant differences were found between group A and group B when operative mortality (2.7% vs 2.3%) and stroke rates (2.7% vs 6.8%) were analyzed. However, 10 years after surgery, freedom from graft failure was significantly better in group A (94.4% +/- 4.4%) than in group B (60.3% +/- 13.4%) ( P = .002). Freedom from graft failure was adversely affected by nonaortic inflow ( P = .002) and axillo-axillary cervical grafts ( P = .0001). Mortality and stroke rates for subgroups having multiple distal anastomoses (2.9%, 2/70 and 4.3%, 3/70), concomitant CABG (5.4%, 2/37 and 0, 0/37), and concomitant CEA (3.8%, 1/26 and 3.8%, 1/26) were similar to those of other patients. For the entire patient group, 10-year rates of actuarial freedom from specific events were death, 68.8% +/- 6.0%; myocardial infarction, 86.7% +/- 4.5%; stroke, 87.0% +/- 4.4%; coronary revascularization, 88.0% +/- 3.6%, and other vascular operation, 79.9% +/- 4.4%.
  
  
  CONCLUSIONS
  Transthoracic arch reconstruction for complex brachiocephalic disease can be done with acceptably low morbidity and mortality similar to those of a less invasive, extrathoracic approach. Furthermore, the transthoracic approach is associated with significantly better long-term freedom from graft failure, possibly because it preserves aortic inflow to the great vessels. Nonetheless, the high frequency of late events in this relatively young patient population reflects the presence of multisystem atherosclerosis and suggests the need for close follow-up and lifestyle modification.
authors: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, 77225, USA.
authors: Thomas J
authors: TJ
authors: Takach
authors: George J
authors: GJ
authors: Reul
authors: Denton A
authors: DA
authors: Cooley
authors: J Michael
authors: JM
authors: Duncan
authors: James J
authors: JJ
authors: Livesay
authors: Igor D
authors: ID
authors: Gregoric
authors: Zvonimir
authors: Z
authors: Krajcer
authors: Roberto D
authors: RD
authors: Cervera
authors: David A
authors: DA
authors: Ott
authors: O H
authors: OH
authors: Frazier
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001161:Arteriosclerosis / Q000601:surgery*; D016122:Brachiocephalic Trunk; D016121:Brachiocephalic Veins; D015897:Comorbidity; D001026:Coronary Artery Bypass; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000601:surgery*