What is the management of brachiocephalic artery occlusion?

Management of Brachiocephalic Artery Occlusion

Symptomatic patients with brachiocephalic artery occlusion should undergo revascularization, with endovascular stenting as first-line therapy for suitable anatomy and surgical bypass for total occlusions or complex lesions. 1

Clinical Presentation and Diagnosis

Brachiocephalic artery occlusive disease may present with various symptoms depending on severity:

• Upper extremity ischemia (arm/hand claudication, paresthesia, rest pain)
• Vertebrobasilar insufficiency (lightheadedness, syncope, vertigo, ataxia, diplopia)
• Transient ischemic attack or stroke
• Asymptomatic blood pressure disparity between arms

Diagnostic evaluation should include:

• Bilateral arm blood pressure measurements (though symmetrical pressures don't rule out disease if bilateral involvement exists) 2
• Auscultation for periclavicular or infraclavicular bruits 1
• Duplex ultrasonography (90% sensitivity, 94% specificity for significant stenosis) 3
  • Look for monophasic flow (indicating >70% stenosis)
  • Flow reversal (indicating subclavian steal syndrome)
  • High-velocity flow (PSV >240 cm/s suggesting >70% stenosis)
• Contrast-enhanced CTA or MRA for definitive diagnosis 1
• Catheter-based angiography for pre-procedural planning 1

Management Algorithm

1. Asymptomatic Patients

• Medical management with antiplatelet therapy and risk factor modification
• Revascularization may be considered in asymptomatic patients requiring coronary bypass with internal mammary artery to preserve blood flow 1

2. Symptomatic Patients

Revascularization is indicated for symptomatic patients using either:

Endovascular Approach (First-line for suitable anatomy)

• Balloon angioplasty with stenting (preferred over angioplasty alone)
• Technical success rates of 98% 1
• Primary patency: 93% at 1 year, 70% at 5 years 1
• Periprocedural complication rate: approximately 15% 1
• Best for:
  • Stenotic lesions (not total occlusions)
  • Favorable anatomy
  • High surgical risk patients

Surgical Approach

• Transthoracic surgical revascularization options:
  • Aorta-innominate bypass
  • Aorta-carotid bypass with subclavian reimplantation
  • Carotid-subclavian bypass
  • Axilloaxillary bypass
• Technical success rates of 100% 1
• Primary patency: 100% at 1 year, 96% at 5 years 1
• Periprocedural complication rate: approximately 6% 1
• Best for:
  • Total arterial occlusions
  • Anatomically complex lesions
  • Embolism source that can be excluded during surgery
  • Failed endovascular intervention

Special Considerations

Common Brachiocephalic Trunk

When a common brachiocephalic trunk is present (where both common carotid arteries and right subclavian artery arise from a single trunk), occlusion poses a severe ischemic threat as three of four primary cerebral blood flow sources are affected 4. Revascularization options include:

• Prosthetic bypass graft from ascending aorta to innominate or left common carotid arteries
• Transarterial endarterectomy
• Careful monitoring for neurologic complications is essential

Perioperative Management

For surgical cases requiring cardiopulmonary bypass:

• Selective antegrade brain perfusion may be provided by direct cannulation of brachiocephalic arteries 1
• Right axillary artery cannulation can maintain cerebral perfusion during reconstruction 5
• Monitoring of brain function using electroencephalography, evoked potentials, or cerebral oximetry 1

Postprocedural Care and Follow-up

• Antiplatelet therapy (aspirin 81-325 mg daily or clopidogrel 75 mg daily)
• Regular surveillance with duplex ultrasonography
• Risk factor modification (smoking cessation, blood pressure control, lipid management)
• Monitor for restenosis, especially after endovascular procedures

Pitfalls and Caveats

• Symmetrical blood pressures in both arms don't rule out brachiocephalic disease if bilateral involvement exists 2
• Coexisting aortic valve disease may mask symptoms of brachiocephalic obstruction 2
• Periprocedural stroke risk is significant with both approaches but higher with surgical intervention
• Long-term patency favors surgical bypass over stenting, but initial complications are higher with surgery

The current evidence suggests that physicians experienced with both techniques should consider a percutaneous catheter-based approach initially when anatomy is suitable, reserving surgery for patients with total arterial occlusion or stenotic lesions anatomically unsuited to catheter intervention 1.