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PATIENT STORY

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A 59-year-old Caucasian woman presented for evaluation after a recent right hemispheric stroke. She had residual short-term memory loss but no sensory or motor deficits. She reported previous episodes of dizziness, syncope, and left arm fatigue upon exertion prior to the stroke. Despite a 60 pack-year cigarette smoking history, she had recently quit and was compliant with her statin and antiplatelet therapy. On physical examination she had a right cervical bruit, absent left radial pulse, and her lower extremity vascular examination was unremarkable. There was significant discrepancy in upper extremity pressures.

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Computed tomography (CT) and digital subtraction arteriogram (DSA) demonstrated occlusion of the left subclavian and the origin of the left common carotid arteries, but the latter was reconstituted by collaterals at the level of the bifurcation (Figure 9-1A). The right common carotid artery (CCA) had greater than 90% ostial stenosis and the right subclavian artery had significant stenosis, as suggested by the poststenotic dilation (Figure 9-1B). The right vertebral artery was dominant (Figure 9-1C). The innominate artery demonstrated diffuse calcific irregularity with moderate distal stenosis (Figure 9-2). The left vertebral artery was patent with retrograde flow on duplex ultrasonography.

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FIGURE 9-1

Anterior view of a computed tomographic arteriography (CTA) three-dimensional (3D) reconstruction demonstrating occlusion of the left carotid and subclavian arteries with collateralization through the thyroid arteries to reconstitute the left internal carotid artery (ICA) at the level of the bifurcation (arrow) (A). Arch arteriogram of the same patient shows stenosis of the origin of the right subclavian (long arrow) and right carotid arteries (short arrow) with poststenotic dilation in the proximal subclavian (arrowhead) (B). Posterior view of CTA 3D reconstruction exhibiting a large dominant right vertebral artery (arrow) (C).

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FIGURE 9-2

Computed tomographic arteriography (CTA) reconstruction of the arch and supra-aortic branch vessels demonstrating scattered atherosclerotic plaque deposition along the arch and heavy disease within the innominate artery (arrow).

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After extensive discussion with the patient regarding the risks and benefits of open versus endovascular management strategies, she proceeded to the operating room for a hybrid procedure. Retrograde open right subclavian artery access was obtained with placement of a balloon expandable stent from the proximal subclavian artery extending into the innominate artery (Figure 9-3A and B). A right subclavian to carotid artery bypass was then constructed with a prosthetic graft, and the proximal common carotid was ligated. She was discharged home on postoperative day 1 (POD1) and had no adverse events. She was doing well with no further neurologic problems at subsequent follow-up.

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