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Brachiocephalic arterial occlusions and stenoses. Manifestations and management of complex lesions.

Complex stenotic and occlusive lesions involving multiple brachiocephalic arteries were encountered in 17 symptomatic patients, 25 to 76 years of age. Symptoms included hemispheric transient ischemic attacks (16), visual symptoms (ten), global cerebral ischemia (11), true syncope (six), upper extremity ischemic symptoms (eight), and frank tissue loss (one). Of 68 brachiocephalic arteries, 53 exhibited hemodynamically significant stenoses, including 21 that were totally occluded. Transthoracic surgical reconstruction consisted of bypass grafting (11), innominate artery endarterectomy (five), or proximal left common carotid endarterectomy with reimplantation into the contralateral carotid artery (one). There were no operative deaths and only one transient perioperative neurologic deficit. All patients had relief of symptoms. When multiple brachiocephalic arterial occlusions and stenoses preclude standard cervical reconstructive procedures, direct transthoracic reconstruction is appropriate and may be undertaken with acceptable risk in properly selected patients.