Hybrid procedures in treatment of multilevel lesions of the brachiocephalic arteries

Background Multilevel significant atherosclerotic disease involving the carotid bifurcation and the proximal ipsilateral common carotid or brachiocephalic arteries presents an uncommon and difficult management problem. Axial (aortocarotid bypass) or extra-anatomic procedures (subclavian–carotid bypass, carotid–carotid bypass, carotid–subclavian transposition) and variations in the performance of thromboendarterectomies are all possibilities in treatment of tandem brachiocephalic arteries stenosis. Although extra-anatomic procedures have excellent patency (90% at 5 years) and durability and avoid the morbidity of median sternotomy, they are usually performed in patients with significant cardiovascular comorbidities who may be detrimentally affected because of the use of general anesthesia and the possible need of prosthetic devices and multiple incisions. The desire to avoid the need for intrathoracic and extra-anatomic reconstructions has fostered the use of transluminal angioplasty and primary stenting of the supra-aortic vessels. Combined or hybrid carotid procedures can offer an easier solution to a sometimes difficult technical problem.