Subclavian-to-internal carotid artery bypass with carotid endarterectomy for total occlusion of the common carotid artery under awake neurologic monitoring: a case series.

Abstract

Background: Total occlusion of the common carotid artery (CCA) from its origin is rare, occurring in less than 1% of brachiocephalic stenoses. Surgical revascularization is technically demanding, especially with tandem severe ipsilateral internal carotid artery (ICA) stenosis. Procedures under regional anesthesia with continuous neurologic monitoring are rarely described.

Objective: To evaluate outcomes of subclavian-to-internal carotid artery bypass with carotid endarterectomy (CEA) in symptomatic patients with total CCA occlusion and severe ipsilateral ICA stenosis under regional anesthesia with awake neurologic monitoring.

Methods: This retrospective single-center case series included 4 symptomatic male patients (mean age 68.0 years, range 59-75) with total CCA occlusion (Riles type 1A) and severe ipsilateral ICA stenosis (80%-95% by NASCET), who underwent subclavian-to-internal carotid bypass with ICA endarterectomy under cervical plexus and supraclavicular brachial plexus block with 0.5% ropivacaine between December 2021 and June 2026. Neurologic status was monitored continuously in awake patients during carotid cross-clamping. Systolic blood pressure was maintained approximately 20 mmHg above preoperative baseline to optimize collateral perfusion.

Results: Primary technical success was 100%. Mean carotid cross-clamping time was 19.3 min (range, 17-21 min). Retrograde ICA stump pressure was ≥40 mmHg in all patients. No intraoperative neurologic deficits, perioperative strokes, transient ischemic attacks, cranial nerve injuries, graft thromboses, or deaths occurred. At the latest available follow-up, all grafts remained patent and no recurrent neurologic events were recorded. Twelve-month follow-up was available for Patients A, C, and D, whereas Patient B had 3 months of follow-up. One patient with contralateral 98% ICA stenosis underwent staged contralateral CEA one month later.

Conclusion: In this small case series, subclavian-to-internal carotid artery bypass combined with ICA endarterectomy under regional anesthesia with awake neurologic monitoring was technically feasible and was associated with favorable observed perioperative and available follow-up outcomes. Larger comparative studies are warranted.