What are the treatment options for innominate artery disease?

Treatment Options for Innominate Artery Disease

Primary Treatment Approach

For focal, high-grade stenotic lesions of the innominate artery, endovascular stenting is the preferred initial approach, while open surgical bypass via median sternotomy is reserved for extensive disease, total occlusions, or when endovascular repair is anatomically unsuitable. 1

Treatment Algorithm Based on Lesion Characteristics

Endovascular Therapy (First-Line for Focal Stenosis)

• Balloon angioplasty with stenting is indicated for focal, high-grade stenotic lesions of the innominate artery, achieving 100% immediate technical success and 78% primary patency at mean 25-month follow-up 1
• Stenting demonstrates comparable long-term outcomes to open surgery with fewer systemic complications 1
• The procedure can be performed percutaneously or through direct carotid arteriotomy to allow flushing of embolic material 2
• Cerebral protection using an occlusive balloon in the carotid artery should be employed during the procedure to prevent embolic complications 2
• Completion angiography must be performed to detect endoleaks, particularly type I endoleaks at graft interfaces 3

Open Surgical Reconstruction (For Extensive Disease)

• Median sternotomy approach is used in 91% of surgical cases and remains the gold standard for extensive innominate artery disease 4
• Bypass grafting (from ascending aorta to innominate artery) is performed in 78% of surgical patients and is preferred over endarterectomy due to lower risk of aortic tear or dissection 2, 4
• Endarterectomy is performed in only 22% of cases and is reserved for specific anatomical situations where bypass is not feasible 4
• Surgical reconstruction achieves excellent outcomes: 98.6% freedom from ipsilateral stroke at 5 and 10 years, and 96.3% primary patency at 10 years 4
• Perioperative mortality is 5.4%, with stroke risk of 3.4% and transient ischemic attack risk of 2.0% 4

Hybrid Approaches (For Complex Anatomy)

• Carotid-to-carotid bypass (right to left common carotid artery) is indicated when sternotomy is contraindicated due to poor health status, prior mediastinal surgery, or prohibitive thoracic surgical risk 2, 5
• Hybrid procedures combining endovascular stenting with surgical bypass can be employed for patients with innominate artery occlusion and concomitant severe contralateral carotid disease 5
• Chimney graft techniques during thoracic endovascular aortic repair (TEVAR) are used when aortic pathology requires coverage of the innominate artery origin 3

Decision-Making Criteria

Choose Endovascular Stenting When:

• Lesion is focal and high-grade stenotic (not total occlusion) 1
• Patient has prohibitive surgical risk for sternotomy 5
• Anatomy is suitable for percutaneous access 1

Choose Open Surgical Bypass When:

• Innominate artery is totally occluded 6, 5
• Disease is extensive involving multiple branch vessels 1
• Aneurysmal disease is present 2
• Endovascular approach has failed or is anatomically unsuitable 1

Choose Hybrid/Alternative Approach When:

• Sternotomy is contraindicated (prior mediastinal surgery, severe comorbidities) 2
• Concomitant severe contralateral carotid disease exists 5
• Aortic arch pathology requires concurrent TEVAR 3

Critical Technical Considerations

• Pre-procedural contrast-enhanced CT is mandatory to evaluate landing zone diameters, lengths, and relationship to side branches 3
• The innominate artery is the first and largest branch of the aortic arch, giving rise to the right subclavian and right common carotid arteries 6
• Careful assessment of aortic arch morphology is essential as it affects technical feasibility of both endovascular and surgical approaches 3

Common Pitfalls to Avoid

• Do not perform endarterectomy routinely - it carries higher risk of aortic tear or dissection compared to bypass grafting 2
• Avoid endovascular intervention for total occlusions - these require open surgical bypass for optimal outcomes 1
• Do not overlook cerebral protection during endovascular procedures - embolic complications can be devastating 2
• Recognize that balloon angioplasty alone is insufficient - stenting is required for durable results 7

Long-Term Outcomes

• Assisted primary patency is 100% for both endovascular and open approaches with appropriate reintervention 1
• Annual mortality rate after surgical reconstruction is 4.4%, primarily from cardiovascular causes (not neurologic) 4
• Freedom from ipsilateral neurologic events is 92.7% at 5 years and 84.0% at 10 years 4
• Reoperation is rarely needed: 95.6% freedom from reoperation at 5 years 4