title: Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades.
abstract: BACKGROUND
  The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction.
  
  
  METHODS
  We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease.
  
  
  RESULTS
  Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%.
  
  
  CONCLUSIONS
  CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX 77225-0345, USA.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Takach
authors.forename: J Michael
authors.initials: JM
authors.lastname: Duncan
authors.forename: James J
authors.initials: JJ
authors.lastname: Livesay
authors.forename: David A
authors.initials: DA
authors.lastname: Ott
authors.forename: Roberto D
authors.initials: RD
authors.lastname: Cervera
authors.forename: Denton A
authors.initials: DA
authors.lastname: Cooley
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000175:diagnosis / Q000266:history / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017536:Carotid Artery, Common / Q000503:physiopathology / Q000601:surgery*; D016893:Carotid Stenosis / Q000175:diagnosis / Q000266:history / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D003251:Constriction, Pathologic; D005260:Female; D049673:History, 20th Century; D049674:History, 21st Century; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D018579:Patient Selection; D012008:Recurrence; D012086:Reoperation; D020521:Stroke / Q000209:etiology; D013348:Subclavian Artery / Q000503:physiopathology / Q000601:surgery*; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000266:history / Q000401:mortality