Urgent : Left Carotid Subclavian Bypass v/s Stent in Subclavian

  My father, age 62 has the following situation :
  1. Done CABG 10 years back. Having recurrent attacks of giddiness and difference in blood pressure in both the upper limbs since last 6 months. His left radial and brachial pulses are very feeble.
  2. His angiography done on June 22nd '98 revealed severe native coronary artery disease with all venous grafts blocked. Severe triple vessel disease. Distal left main has 70-80% stenosis. LAD long segment proximal 50% stenosis. Native vessels are tiny. Proximal Left Subclavian has 90% stenosis with reversal of flow in vertebrals. RCA has 100% ostial block. There is also a 70% block in the abdominal aorta below the renals. LIMA to LAD is patent and seen filling retrograde from native LAD. Echo LVEF 58%. Carotid Doppler shows large left vertebral with retrograde flow. Otherwise normal carotid and vertebral arteries.
  3. I understand that a carotid subclavian bypass using prosthetic dacron has the risks of stroke, heart attack, damage to phrenal nerve to diaphragm, damage to auditory nerve, damage to thoracic lymph duct.
  On the other hand, stent placement has the risk of clot going into and blocking the LIMA and thus putting life at risk. Also in-stent restenosis is another problem. Which is the better alternative in your opinion? What other associated risks are there?
  Please reply urgently.
  Alok

[CCF CARDIO MD APS]

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Dear Alok,
The reason why I have not responded urgently as you requested is that really there
is no right answer to the question 'which procedure should my father have?'
Although one might say that whichever procedure is least likely to place the
LIMA graft (the only blood supply to the heart) in jeopardy is the route to take.
Your father's atherosclerosis is fairyly severe as well as diffuse and this makes
re-stenosis a concern but surely this is not a guarentee on stent placement.  I will
speak one other colleague and return soon with more.   Good Luck.  Information
provided in the heart forum is intended for general medical information only,
actual diagnosis and treatment can only be made by your physician(s).

[havalinda]

A related discussion, Risk of placing stent in carotid artery. was started.