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

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.