++
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.
++
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.
++++++
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.
++