Revascularisation for symptomatic common carotid artery occlusion: neurosurgical practice and outcomes of subclavian artery-common carotid artery bypass grafting

Background Complete common carotid artery (CCA) occlusion (CCAO) lacks standardised treatment guidelines and is frequently associated with severe complications. Subclavian artery-to-CCA bypass grafting (SCBG) provides a viable revascularisation strategy, yet its neurosurgical application remains underexplored. This study evaluated the clinical efficacy and technical nuances of SCBG from a neurosurgical perspective. Methods This retrospective study enrolled 20 symptomatic patients with CCAO demonstrating ipsilateral hypoperfusion on CT perfusion (CTP). Preoperative evaluations included CT angiography, CTP and high-resolution MRI. Surgical indications comprised recurrent ischaemic events and significant ipsilateral hypoperfusion. SCBG was performed using prosthetic grafts (PGs), with intraoperative patency verified via indocyanine green angiography. Postoperative protocols for anticoagulation, antiplatelet and statin therapies were standardised. Results The median operative duration was 255.5 min (IQR 202.25–319.75 min), with a median estimated blood loss of 50 mL (IQR 20–50 mL). The primary patency rate was 85%, with initial graft occlusion occurring in three cases. Two cases were managed conservatively, and one underwent successful emergency thrombectomy, restoring patency (final secondary patency 90%). Complications included asymptomatic acute ischaemic strokes (2/20), pleural effusion (1/20) and extended intensive care unit stay (1/20). During follow-up, the median postoperative modified Rankin Scale was 0. CTP volumetric analysis confirmed a significant reduction in the time to maximum>6 s hypoperfusion volume (p=0.004) in the patent cohort. Conclusions Our findings suggest that SCBG presents a high-flow revascularisation option for symptomatic CCAO, with initial evidence suggesting acceptable safety and an 85% primary and 90% final patency rate using PGs. It may address a therapeutic gap when endovascular techniques or superficial temporal artery-to-middle cerebral artery bypasses are unsuitable. However, these conclusions are limited by our small sample size and lack of a control group and should be considered preliminary until confirmed by larger studies with long-term follow-up.