Concomitant Brachiocephalic and Coronary Artery Disease: Outcome and Decision Analysis

Background In patients with coronary artery disease, concomitant brachiocephalic disease may affect outcome and influence decision making regarding operative staging, technique, and choice of conduit. Methods Eighty consecutive patients (mean age, 59.3 years; 60.0% male) with concomitant brachiocephalic and coronary artery disease were identified either before (group A, n = 48) or after (group B, n = 32) coronary artery bypass grafting. Patients who had symptomatic brachiocephalic and coronary artery disease before surgery underwent concomitant brachiocephalic reconstruction and coronary artery bypass grafting using either all-vein coronary conduits (n = 41) or vein-and-internal mammary artery conduits (n = 7). Patients who had coronary-subclavian steal syndrome after coronary artery bypass (group B, n = 32) underwent either surgical (n = 5) or endovascular (n = 27) brachiocephalic reconstruction only. Results All patients were asymptomatic after intervention. Operative mortality was 4.2% for group A and 3.1% for group B. The perioperative stroke rate was 2.1% for group A and 0% for group B. Actuarial 10-year freedom from specific events for group A was as follows: death 59.9 ± 12.8%, brachiocephalic restenosis 100%, coronary-subclavian steal syndrome 100%, myocardial infarction 83.5 ± 10.5%, stroke 82.1 ± 9.9%, redo coronary artery bypass grafting 95.8 ± 4.1%, other vascular operation 82.2 ± 8.9%, and adverse cardiac outcome (death, redo coronary artery bypass grafting, or myocardial infarction) 52.9% ± 13.2% (for patients with all-vein conduits) or 100% (for patients with vein-and-internal mammary artery conduits). At midterm follow-up (mean, 2.92 years), both the surgical and the endovascular treatment subgroups of group B had 100% brachiocephalic patency. Conclusions Long-term results in a limited population support continued evaluation of concomitant brachiocephalic reconstruction and coronary artery bypass grafting with use of the internal mammary artery conduit in an attempt to improve late survival in patients with concomitant disease. The excellent midterm brachiocephalic patency after either surgical or endovascular treatment of patients with coronary-subclavian steal syndrome supports continued evaluation of both methods.