AXILLARY-AXILLARY BY-PASS GRAFT AN ALTERNATIVE TECHNIQUE
FOR
REPAIR
OF THE
SUBCLAVIAN STEAL SYNDROME
THOMAS M. MAXWELL, M.D., F.R.C.S.(C).,* ERICK POLLAK, M.D., JOSEPH L. ALEXANDER, M.D., F.A.C.S., AND ASHIS K. MANDAL, M.D., F.R.C.S.(C)., F.A.C.S.
Since aortic arteriographic studies are being performed with increasing an increased number of stenosis and obstructions of the inominate and subclavian arteries are being detected. It is generally agreed that the radiological findings of vascular obstruction in an asymptomatic patient does not require surgical correction. 1, 2However, cerebral ischaemic symptoms may result from a steal by the upper extremity from the cerebral circulation via the vertebral system to compensate for the deficit. Corrective procedures for this disease include both the direct intra-thoracic approach to the vessel and extra-thoracic by-pass procedures. Often patients seen with this syndrome may have coexistent arterial disease in other vital organs and intra-thoracic procedures are contra-indicated because of their increased morbidity and mortality. Extra-thoracic by-pass procedures include a choice between carotid-subclavian, subclavian-subclavian, femoro-axillary, carotid-axillary, carotid-vertebral and axillary-axillary by-pass as well as vertebral artery ligation.8~ 10, 11, 13, 144 While each of these procedures have their merits and proponents our recent experience suggests that axillary-axillary by-pass may be the optimal procedure for the high risk patient. The following case represents the axillary-axillary by-pass graft utilized in a high risk patient to prevent cerebral and left upper extremity circulatory insufficiency, following failure of the left carotid subclavian by-pass graft.
frequency,
CASE REPORT
A. B., (MLK # 03 09 49), a 59-year-old Black male, double amputee who was admitted to Martin Luther King, Jr. County Hospital September 12, 1973 gave a four4 month history of incapacitating dizziness, diplopia and painful claudication of his left upper extremity when he manipulated his wheelchair for more than a block. He lived alone, cooked his own meals and cared for himself. In 1971 he had several operations for vascular insufficiency performed at another institution, culminating in a right above-knee amputation and left knee disarticulation. Post-operatively he developed a myocardial infarction and a post-transfusional hepatitis. He subsequently developed a &dquo;subclavian steal&dquo; syndrome and was admitted to Martin Luther King, Jr. Hospital in * Department of Surgery, University British Columbia, St. Paul’s Hospital, 1081 Burrard St. Vancouver. British Columbia, Canada. From the Division of Surgery, Martin Luther King, Jr. General Hospital and Department of Surgery, Charles R Drew Postgraduate Medical School, Los Angeles, California.
58
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
59
FIG. 1. An aortic arch study demonstrating occlusion of the carotid subclavian graft (upper arrows) and the subclavian artery stenosis (lower arrow).
November 1972 where he underwent a left carotid to subclavian by-pass graft utilizing an 8mm Debakey Knitted Dacron graft. He had a good post-operative result and remained asymptomatic until May 1973. Physical examination on this admission to MLK* Hospital revealed a diminished left subclavian pulse and absent left arm pulses. A loud bruit was audible over the left supra-clavicular region. Doppler studies revealed a pressure of 140/88mm of Hg in right upper extremity as compared to 90/70 mm of Hg in his left upper extremity. In hospital investigation established the additional diagnosis of chronic obstructive pulmonary disease, mild adult onset diabetes, type IV hyperlipoproteinemia and generalized artherosclerotic disease. An aortic arch study demonstrated occlusion of the carotid to subclavian by-pass graft and stenosis of the left subclavian artery as well as retrograde filling of the left vertebral artery from the basilar system (Figure 1). The extra-cranial carotid vessels were free of disease. Additionally, there was minimal narrowing of both vertebral arteries at their origins from the subclavian arteries. On September 17, 1973 under general anesthesia, he underwent an axillary-axillary by-pass with a 8mm Valour Debakey graft through a pre-sternal subcutaneous tunnel. The operative technique is described below. He tolerated the procedure well and became symptom free. Immediately *MLK-Martin Luther King Hospital.
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
60
post-operation Doppler testing revealed a right arm pressure of 145/88mm of Hg and left arm pressure of 158/90mm of Hg with good pulses in both arms. At four months follow-up his Doppler pressures remained essentially unchanged and he has remained asymptomatic. OPERATIVE TECHNIQUE
Under endotracheal general anesthesia, the patient was placed in a semi-erect position with a sand bag beneath the shoulders and both arms abducted. An incision was made below the middle one-third of the right clavicle. The incision was carried down through the clavicular head of pectoralis major muscle and through the clavipectoral fascia. The insertion of the pectoralis major muscle was retracted laterally to isolate the first and second portions of the axillary artery. A similar anatomical dissection was then carried out below the middle one-third of the left clavicle and a subcutaneous tunnel was made across the manubrium. After the patient was heparinized with intravenous injection of 5,000 units of heparin a pre-clotted 8mm Debakey velour knitted graft was then sutured end to side of the right axillary artery. The graft was then brought through the pre-sternal subcutaneous tunnel and after having the exact length, the other end of the graft was inserted end to side to the left axillary artery. After the clamps were removed blood flow through the graft was established. The wound was then closed in anatomical layers. Postoperative Doppler testing was done in both arms as reported above. ANATOMICAL CONSIDERATIONS
The pectoralis minor muscle may be retracted laterally or its insertion removed from the coracoid process to gain exposure of the second portion of the axillary artery. This maneuver will give excellent exposure of the vessel. The supreme thoracic is the only branch of the first portion of the axillary artery and does not need to be sacrificed. The thoracic acrominal and lateral thoracic arteries are the branches of second portion of axillary artery. It is not usually necessary to ligate either of these branches of the axillary artery, but we recommend sacrificing the thoracoacrominal branch of the axillary artery if necessary to facilitate the anastomosis and to have a bigger arteriotomy site for the anastomosis. The median nerve and its two roots of origin are most important structures to consider when one uses the anterior surface of the second portion of the axillary artery. If the anastomosis is made too close to these cords one may get a transient median nerve compression post-operatively. We prefer to utilize the anterior or antero-inferior aspect of the first or second portion of the axillary artery for the arteriotomy and anastomosis of the graft. It avoids adjacent neurovascular bundles and gives better anatomical interposition of graft between the two axillary arteries.
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
61 DISCUSSION
z
Reversal of blood flow in one vertebral artery at the level of the basilar system to supply the ispilateral subclavian artery was first described by Contorni in March 1960. Reivich, et al, discussed the syndrome definitively in 1961, with confirmation by experimental and flow studies. The term &dquo;subclavian steal&dquo; was introduced at that time, and apt description of the physiological events without reference to neurological defects that are often absent. Usually atherosclerosis is the most common etiologic factor resulting in subclavian or inominate artery stenosis or occlusion. Other etiological factors such as congenital aresia of the left subclavian artery and embolic occlusion have been reported. Iatrogenic instances may follow the use of left subclavian artery for by-pass of an aortic coarctation resection or as input of a canula
during cardio-pulmonary by-pass, rarely following Blalock-Taussig procedure, or secondary to non-specific arteritis or Takayasu’s disease.5 This patient re-developed a classic subclavian steal syndrome secondary to occlusion of left carotid to subclavian by-pass graft. The patient had lost both 5
his lower extremities integrity of his upper life. Re-operation in altered anatomy and
due to atherosclerotic occlusive disease. The functional extremities was essential for him to lead an independent the supraclavicular area is technically difficult due to may be hazardous at times. Carotid-subclavian artery by-pass implies partial or total transient occlusion of the carotid artery while the anastomosis is being made. There is a possibility of extra-pleural hemorrhage 1 and a possibility of a &dquo;steal&dquo; from the cerebral circulation as has been mentioned by some authors5, 6 while negated by others .7, ’ However, there seems to be an agreement that this steal may occur when a narrowing at the site of anastomosis of the donor carotid artery exists.9 Subclavian-subclavian by-pass obviates most of the above mentioned physiological hemodynamic disputes 10 but on the other hand, the anastomosis is technically more difficult to perform than axillary-axillary anastomosis. 11 In 1971, Myers, et al’ used axillary-axillary cross over by-pass under local anesthesia to restore the circulation to the arm of a very severely ill patient. A femoro-axillary by-pass under local anesthesia can be used for cerebro-vascular insufficiency as suggested by Sproule.11 However, it requires a longer prosthetic graft, a longer subcutaneous tunnel and crosses lumbo-sacral and hip joints. Because of these shortcomings, one may presume there may be a higher rate of failure of such a graft secondary to kinking, thrombosis,
infection,
etc.
The first or second portion of the axillary artery are chosen for the anastomosis for anatomical simplicity. Also, these segments of the axillary artery are relatively fixed and do not cross over a joint. The study of the Doppler pressure post-operatively showed normal circulation to both extremities without decreasing flow in the donor artery. Although in this case general
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
62 anesthesia was utilized, local anesthesia may be used in high risk patients had been pointed out by Sproule 11 in the past.
as
CONCLUSION
The report is an example of the usefulness of the axillary-axillary by-pass as alternative treatment of the subclavian steal syndrome when other corrective methods failed and can be used initially as the procedure of choice in a high risk patient or when general anesthesia is contra-indicated. an
BIBLIOGRAPHY 1.
2. 3. 4.
5. 6.
7. 8.
9. 10.
11. 12. 13. 14. 15.
Con, J.: Alternative Methods in Arterial Reconstruction, Surgical Clinics of Bergan, North America, 51: 85-97, February 1971. Wylie, E. J.: In Discussion of: Vascular Steal Phenomenon, An Experimental Study of Ehernfeld, et al, American Journal of Surgery, 116: 192-197, August 1968. Contorni, L.: The Vertebro-vertebral Collateral Circulation in Obliteration of the Subclavian Artery at its Origin, Minerva Chir., 15: 268, 1960. Reivich, M., Holling, H. E., Roberts, B., & Toole, J. F.: Reversal of Blood Flow through the Vertebral Artery and its Effect on Cerebral Circulation, New England Journal of Medicine, 265: 878, 1961. Dumanian, A. V., Frahm, C. J., Pascale, L. R., et al: The Surgical Treatment of the Subclavian Steal Syndrome, Journal of Thoracic and Cardiovascular Surgery, 50: 22, 1965. Harper, J. A., Golfing, A. K., Mazzei, E. A., & Cannon, J. A.: An Experimental Hemodynamic Study of the Subclavian Steal Syndrome, Surgery, Gynecology and Obstetrics, 124: 1212, 1967. Ehrenfeld, W. K., Harris, J. D., & Wylie, E. J.: Vascular Steal Phenomenon. An Experimental Study, American Journal of Surgery, 116: 192-197, August 1968. Deithrich, E. B., Garrett, H. E., Ameriso, J., et al: Occlusive Disease of the Common Carotid and Subclavian Arteries treated by Carotid Subclavian by-pass, Analysis of 125 cases, American Journal of Surgery, 114: 800, 1967. Lord, R. S. A., & Ehrenfeld, W. K.: Carotid Subclavian by-pass, a Hemo dynamic Study, Surgery, 66: 521, 1969. Mozersky, D. J., Summer, D. S., Barnes, R. W., & Strandness, D. E.: Subclavian Revascularization by means of a Subcutaneous Axillary-Axillary Graft, Archives of Surgery, 106: 20-23, January 1973. Sproule, G.: Femoral-Axillary by-pass for Cerebral Vascular Insufficiency, Archives of Surgery, 103: 746-747, December 1971. Myers, W. O., Lawton, B. R., & Sautter, R. D.: Axillo-Axillary By-pass Graft, Journal of the American Medical Association, 217: 825, August 9, 1971. Finkelstein, N. M., Byer, A., & Rush, B. F.: Subclavian-Subclavian By-pass for the Subclavian Steal Syndrome, Surgery, 71: 142-145, 1972. Forestner, J. E., Ghosh, S. K., Bergan, J. J., & Conn, J.: Subclavian-Subclavian Bypass for Correction of the Subclavian Steal Syndrome, Surgery, 71: 136-141, January 1972. Jacobson, J. H., Mozersky, D. J., Mitty, H. A., & Brothers, M. J.: Axillary By-pass for the Subclavian Steal Syndrome, Archives of Surgery, 106: 24-27 January 1973. J.
J., &
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
FOR
REPAIR
OF THE
SUBCLAVIAN STEAL SYNDROME
THOMAS M. MAXWELL, M.D., F.R.C.S.(C).,* ERICK POLLAK, M.D., JOSEPH L. ALEXANDER, M.D., F.A.C.S., AND ASHIS K. MANDAL, M.D., F.R.C.S.(C)., F.A.C.S.
Since aortic arteriographic studies are being performed with increasing an increased number of stenosis and obstructions of the inominate and subclavian arteries are being detected. It is generally agreed that the radiological findings of vascular obstruction in an asymptomatic patient does not require surgical correction. 1, 2However, cerebral ischaemic symptoms may result from a steal by the upper extremity from the cerebral circulation via the vertebral system to compensate for the deficit. Corrective procedures for this disease include both the direct intra-thoracic approach to the vessel and extra-thoracic by-pass procedures. Often patients seen with this syndrome may have coexistent arterial disease in other vital organs and intra-thoracic procedures are contra-indicated because of their increased morbidity and mortality. Extra-thoracic by-pass procedures include a choice between carotid-subclavian, subclavian-subclavian, femoro-axillary, carotid-axillary, carotid-vertebral and axillary-axillary by-pass as well as vertebral artery ligation.8~ 10, 11, 13, 144 While each of these procedures have their merits and proponents our recent experience suggests that axillary-axillary by-pass may be the optimal procedure for the high risk patient. The following case represents the axillary-axillary by-pass graft utilized in a high risk patient to prevent cerebral and left upper extremity circulatory insufficiency, following failure of the left carotid subclavian by-pass graft.
frequency,
CASE REPORT
A. B., (MLK # 03 09 49), a 59-year-old Black male, double amputee who was admitted to Martin Luther King, Jr. County Hospital September 12, 1973 gave a four4 month history of incapacitating dizziness, diplopia and painful claudication of his left upper extremity when he manipulated his wheelchair for more than a block. He lived alone, cooked his own meals and cared for himself. In 1971 he had several operations for vascular insufficiency performed at another institution, culminating in a right above-knee amputation and left knee disarticulation. Post-operatively he developed a myocardial infarction and a post-transfusional hepatitis. He subsequently developed a &dquo;subclavian steal&dquo; syndrome and was admitted to Martin Luther King, Jr. Hospital in * Department of Surgery, University British Columbia, St. Paul’s Hospital, 1081 Burrard St. Vancouver. British Columbia, Canada. From the Division of Surgery, Martin Luther King, Jr. General Hospital and Department of Surgery, Charles R Drew Postgraduate Medical School, Los Angeles, California.
58
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
59
FIG. 1. An aortic arch study demonstrating occlusion of the carotid subclavian graft (upper arrows) and the subclavian artery stenosis (lower arrow).
November 1972 where he underwent a left carotid to subclavian by-pass graft utilizing an 8mm Debakey Knitted Dacron graft. He had a good post-operative result and remained asymptomatic until May 1973. Physical examination on this admission to MLK* Hospital revealed a diminished left subclavian pulse and absent left arm pulses. A loud bruit was audible over the left supra-clavicular region. Doppler studies revealed a pressure of 140/88mm of Hg in right upper extremity as compared to 90/70 mm of Hg in his left upper extremity. In hospital investigation established the additional diagnosis of chronic obstructive pulmonary disease, mild adult onset diabetes, type IV hyperlipoproteinemia and generalized artherosclerotic disease. An aortic arch study demonstrated occlusion of the carotid to subclavian by-pass graft and stenosis of the left subclavian artery as well as retrograde filling of the left vertebral artery from the basilar system (Figure 1). The extra-cranial carotid vessels were free of disease. Additionally, there was minimal narrowing of both vertebral arteries at their origins from the subclavian arteries. On September 17, 1973 under general anesthesia, he underwent an axillary-axillary by-pass with a 8mm Valour Debakey graft through a pre-sternal subcutaneous tunnel. The operative technique is described below. He tolerated the procedure well and became symptom free. Immediately *MLK-Martin Luther King Hospital.
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
60
post-operation Doppler testing revealed a right arm pressure of 145/88mm of Hg and left arm pressure of 158/90mm of Hg with good pulses in both arms. At four months follow-up his Doppler pressures remained essentially unchanged and he has remained asymptomatic. OPERATIVE TECHNIQUE
Under endotracheal general anesthesia, the patient was placed in a semi-erect position with a sand bag beneath the shoulders and both arms abducted. An incision was made below the middle one-third of the right clavicle. The incision was carried down through the clavicular head of pectoralis major muscle and through the clavipectoral fascia. The insertion of the pectoralis major muscle was retracted laterally to isolate the first and second portions of the axillary artery. A similar anatomical dissection was then carried out below the middle one-third of the left clavicle and a subcutaneous tunnel was made across the manubrium. After the patient was heparinized with intravenous injection of 5,000 units of heparin a pre-clotted 8mm Debakey velour knitted graft was then sutured end to side of the right axillary artery. The graft was then brought through the pre-sternal subcutaneous tunnel and after having the exact length, the other end of the graft was inserted end to side to the left axillary artery. After the clamps were removed blood flow through the graft was established. The wound was then closed in anatomical layers. Postoperative Doppler testing was done in both arms as reported above. ANATOMICAL CONSIDERATIONS
The pectoralis minor muscle may be retracted laterally or its insertion removed from the coracoid process to gain exposure of the second portion of the axillary artery. This maneuver will give excellent exposure of the vessel. The supreme thoracic is the only branch of the first portion of the axillary artery and does not need to be sacrificed. The thoracic acrominal and lateral thoracic arteries are the branches of second portion of axillary artery. It is not usually necessary to ligate either of these branches of the axillary artery, but we recommend sacrificing the thoracoacrominal branch of the axillary artery if necessary to facilitate the anastomosis and to have a bigger arteriotomy site for the anastomosis. The median nerve and its two roots of origin are most important structures to consider when one uses the anterior surface of the second portion of the axillary artery. If the anastomosis is made too close to these cords one may get a transient median nerve compression post-operatively. We prefer to utilize the anterior or antero-inferior aspect of the first or second portion of the axillary artery for the arteriotomy and anastomosis of the graft. It avoids adjacent neurovascular bundles and gives better anatomical interposition of graft between the two axillary arteries.
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
61 DISCUSSION
z
Reversal of blood flow in one vertebral artery at the level of the basilar system to supply the ispilateral subclavian artery was first described by Contorni in March 1960. Reivich, et al, discussed the syndrome definitively in 1961, with confirmation by experimental and flow studies. The term &dquo;subclavian steal&dquo; was introduced at that time, and apt description of the physiological events without reference to neurological defects that are often absent. Usually atherosclerosis is the most common etiologic factor resulting in subclavian or inominate artery stenosis or occlusion. Other etiological factors such as congenital aresia of the left subclavian artery and embolic occlusion have been reported. Iatrogenic instances may follow the use of left subclavian artery for by-pass of an aortic coarctation resection or as input of a canula
during cardio-pulmonary by-pass, rarely following Blalock-Taussig procedure, or secondary to non-specific arteritis or Takayasu’s disease.5 This patient re-developed a classic subclavian steal syndrome secondary to occlusion of left carotid to subclavian by-pass graft. The patient had lost both 5
his lower extremities integrity of his upper life. Re-operation in altered anatomy and
due to atherosclerotic occlusive disease. The functional extremities was essential for him to lead an independent the supraclavicular area is technically difficult due to may be hazardous at times. Carotid-subclavian artery by-pass implies partial or total transient occlusion of the carotid artery while the anastomosis is being made. There is a possibility of extra-pleural hemorrhage 1 and a possibility of a &dquo;steal&dquo; from the cerebral circulation as has been mentioned by some authors5, 6 while negated by others .7, ’ However, there seems to be an agreement that this steal may occur when a narrowing at the site of anastomosis of the donor carotid artery exists.9 Subclavian-subclavian by-pass obviates most of the above mentioned physiological hemodynamic disputes 10 but on the other hand, the anastomosis is technically more difficult to perform than axillary-axillary anastomosis. 11 In 1971, Myers, et al’ used axillary-axillary cross over by-pass under local anesthesia to restore the circulation to the arm of a very severely ill patient. A femoro-axillary by-pass under local anesthesia can be used for cerebro-vascular insufficiency as suggested by Sproule.11 However, it requires a longer prosthetic graft, a longer subcutaneous tunnel and crosses lumbo-sacral and hip joints. Because of these shortcomings, one may presume there may be a higher rate of failure of such a graft secondary to kinking, thrombosis,
infection,
etc.
The first or second portion of the axillary artery are chosen for the anastomosis for anatomical simplicity. Also, these segments of the axillary artery are relatively fixed and do not cross over a joint. The study of the Doppler pressure post-operatively showed normal circulation to both extremities without decreasing flow in the donor artery. Although in this case general
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
62 anesthesia was utilized, local anesthesia may be used in high risk patients had been pointed out by Sproule 11 in the past.
as
CONCLUSION
The report is an example of the usefulness of the axillary-axillary by-pass as alternative treatment of the subclavian steal syndrome when other corrective methods failed and can be used initially as the procedure of choice in a high risk patient or when general anesthesia is contra-indicated. an
BIBLIOGRAPHY 1.
2. 3. 4.
5. 6.
7. 8.
9. 10.
11. 12. 13. 14. 15.
Con, J.: Alternative Methods in Arterial Reconstruction, Surgical Clinics of Bergan, North America, 51: 85-97, February 1971. Wylie, E. J.: In Discussion of: Vascular Steal Phenomenon, An Experimental Study of Ehernfeld, et al, American Journal of Surgery, 116: 192-197, August 1968. Contorni, L.: The Vertebro-vertebral Collateral Circulation in Obliteration of the Subclavian Artery at its Origin, Minerva Chir., 15: 268, 1960. Reivich, M., Holling, H. E., Roberts, B., & Toole, J. F.: Reversal of Blood Flow through the Vertebral Artery and its Effect on Cerebral Circulation, New England Journal of Medicine, 265: 878, 1961. Dumanian, A. V., Frahm, C. J., Pascale, L. R., et al: The Surgical Treatment of the Subclavian Steal Syndrome, Journal of Thoracic and Cardiovascular Surgery, 50: 22, 1965. Harper, J. A., Golfing, A. K., Mazzei, E. A., & Cannon, J. A.: An Experimental Hemodynamic Study of the Subclavian Steal Syndrome, Surgery, Gynecology and Obstetrics, 124: 1212, 1967. Ehrenfeld, W. K., Harris, J. D., & Wylie, E. J.: Vascular Steal Phenomenon. An Experimental Study, American Journal of Surgery, 116: 192-197, August 1968. Deithrich, E. B., Garrett, H. E., Ameriso, J., et al: Occlusive Disease of the Common Carotid and Subclavian Arteries treated by Carotid Subclavian by-pass, Analysis of 125 cases, American Journal of Surgery, 114: 800, 1967. Lord, R. S. A., & Ehrenfeld, W. K.: Carotid Subclavian by-pass, a Hemo dynamic Study, Surgery, 66: 521, 1969. Mozersky, D. J., Summer, D. S., Barnes, R. W., & Strandness, D. E.: Subclavian Revascularization by means of a Subcutaneous Axillary-Axillary Graft, Archives of Surgery, 106: 20-23, January 1973. Sproule, G.: Femoral-Axillary by-pass for Cerebral Vascular Insufficiency, Archives of Surgery, 103: 746-747, December 1971. Myers, W. O., Lawton, B. R., & Sautter, R. D.: Axillo-Axillary By-pass Graft, Journal of the American Medical Association, 217: 825, August 9, 1971. Finkelstein, N. M., Byer, A., & Rush, B. F.: Subclavian-Subclavian By-pass for the Subclavian Steal Syndrome, Surgery, 71: 142-145, 1972. Forestner, J. E., Ghosh, S. K., Bergan, J. J., & Conn, J.: Subclavian-Subclavian Bypass for Correction of the Subclavian Steal Syndrome, Surgery, 71: 136-141, January 1972. Jacobson, J. H., Mozersky, D. J., Mitty, H. A., & Brothers, M. J.: Axillary By-pass for the Subclavian Steal Syndrome, Archives of Surgery, 106: 24-27 January 1973. J.
J., &
Downloaded from ves.sagepub.com at Bobst Library, New York University on May 26, 2015
