Between January 1, 1969, and December 31, 1984, 55 operative procedures were carried out in 47 patients to correct subclavian-axillary artery lesions resulting from compression at the thoracic outlet. The most common causes of compression were a long cervical rib (27) and an anomalous first rib (15). Presenting features included claudication, vasomotor phenomena, digital gangrene, and acute limb-threatening ischemia. A combined supraclavicular and infraclavicular approach was preferred. Decompression was best achieved by excision of the cervical rib and the first rib and division of all soft tissue elements. The most common methods of arterial repair were resection-anastomosis (23) and replacement of vein graft (11). Embolic occlusions were frequently present (35). Axillary emboli were amenable to direct revascularization at the time of subclavian artery repair. If possible, more-distal embolic occlusions were managed without recourse to embolectomy catheter manipulations. The mean follow-up was 5 years 8 months (range 4 months to 16 years). Patients were assessed clinically, and the arterial repair was monitored by Doppler ultrasonography, B-mode scanning, and digital subtraction angiography. Of the 39 patients available for follow-up, 35 had no symptoms and four had residual claudication. There were no amputations. In the remaining cases the subclavian-axillary artery segment showed no hemodynamic or anatomic abnormality.

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Between January 1978 and December 1986, 69 polytetrafluoroethylene bypass grafts on the ascending aorta were placed in 53 patients with atherosclerotic occlusive disease of the innominate and left common carotid arteries. Thirty-six patients had symptoms predominantly of amaurosis fugax, verebrobasilar ischemia, and upper limb ischemia. The remaining 17 patients had no symptoms but had severe hemodynamically significant occlusive disease. All operations were accomplished via median sternotomy. One patient died after surgery (operative mortality rate 1.9%), and one patient had minor postoperative neurologic deficit that partially improved on long-term follow-up. Patency of the reconstruction was routinely assessed by a Doppler device combining (1) a continuous wave Doppler and (2) real-time mechanical sector B-mode imaging with frequencies of 3.5 MHz and 7.5 MHz. There were two early asymptomatic occlusions; one was related to a technical error that was successfully revised and the other to low systemic perfusion. The mean follow-up time was 50.5 months. Two patients were lost to follow-up and a further six patients died, for a cumulative 5-year survival rate of 84.9%. One patient had only partial improvement in symptoms and one patient sustained a late postoperative neurologic deficit after internal carotid occlusion distal to a patent aortocarotid bypass. The remaining patients were free of symptoms. There were no infective complications. All the patients underwent late assessment by Doppler ultrasonography and B-mode scanning. One asymptomatic occlusion was thereby identified to be a result of diminished runoff. The overall secondary patency rate at 5 years was 96.1%.(ABSTRACT TRUNCATED AT 250 WORDS)