Combined carotid endarterectomy and bypass for multi-level supra-aortic occlusive disease.

Occlusion of the subclavian artery is an important cause of upper limb ischaemia and vertebrobasilar insufficiency. When associated with carotid artery occlusion, management becomes complex and technically demanding. Surgical revascularisation remains an effective option in selected patients. We report a female in her 60s who presented with giddiness and left upper limb pain, with clinical evidence of chronic ischaemia. Doppler ultrasound revealed monophasic flow in the left axillary artery, CT angiography showed a short-segment chronic total occlusion of the left subclavian artery at its origin along with complete occlusion of the left common and internal carotid arteries. The patient underwent left common carotid endarterectomy with carotid-to-subclavian bypass via supraclavicular approach. There was restoration of pulses in the left upper limb and complete resolution of giddiness. Follow-up Doppler imaging confirmed good flow in the upper limb arteries, demonstrating the effectiveness of this combined surgical approach in complex supra-aortic occlusive disease.