Early and Mid-Term Outcomes of Open versus Endovascular Left Subclavian Artery Debranching for Thoracic Aortic Diseases

Abstract

Purpose: To compare open versus endovascular left subclavian artery debranching for thoracic endovascular aortic repair of thoracic aortic pathologies. Methods: This is a retrospective study of patients receiving left subclavian artery debranching in our institution from October 2009 to January 2020. The primary outcome was freedom from aortic reintervention. Secondary outcomes were type I endoleaks, left subclavian artery (LSA) debranching failure, stroke, technical or clinical success, procedure-related reintervention, as well as 30-day or overall all-cause and aorta-related mortality. Results: Forty-eight patients received parallel graft-based (n = 24, ENDO; median age 75 years [70-80 years]) or open (n = 24, OPEN; median age 71 years [59-75 years]) debranching for type B aortic dissection (n = 25), degenerative aneurysm (n = 12), type IA endoleak (n = 6), suture-associated (n = 3) or ostial LSA aneurysm (n = 1), or penetrating aortic ulcer (n = 1). The median follow-up was 36 months (13-61 months). After 16 months, aortic reintervention-free survival in groups OPEN and ENDO was 91% (95% confidence interval [CI]: 79 to 100%) and 86% (73 to 100%) (p = 0.71), respectively. After 36 months, all-cause survival in groups OPEN and ENDO was 74% (95% CI: 55 to 99%) and 79% (95% CI: 64 to 97%) (p = 0.74), respectively; freedom from aorta-related mortality was 81% (95% CI: 62 to 100%) and 91% (95% CI: 80 to 100%) (p = 0.78), respectively. Group OPEN presented less type I endoleaks (OPEN/ENDO = 3/19, p <0.001) and higher technical (OPEN/ENDO = 81/36%, p = 0.003) and clinical success rates (OPEN/ENDO = 67/36%, p = 0.047). No statistical differences were found for other outcomes. Conclusion: Both strategies achieved comparable reintervention and mortality rates, but open debranching should be preferred due to its higher technical and clinical success and less type I endoleaks.

Physician-Modified TEVAR versus Hybrid Repair of the Proximal Descending Thoracic Aorta

“…It is also of note that the duration of the pmTEVAR operation was, on average, 82 min shorter, compared to the hybrid operation which is not to underestimate especially by polymorbid and high-risk patients. The literature review reveals that this issue is supported by another authors [ 7 ].…”

“…There are several endovascular options for proximal extension of the landing zone in the aortic arch with preservation of the blood flow in the LSCA. The chimney TEVAR with parallel implantation of a covered stent in the LSCA is a feasible alternative, but is connected with the potential risk of gutter endoleak [ 6 , 7 ]. Custom-made stent grafts are also available, but with long production time, and they are not appropriate to be implanted in acute settings [ 8 ].…”

Determination of the gained proximal sealing zone length after debranching of the left subclavian artery in thoracic endovascular aortic repair

“…Besides surgical options, such as CSB SCT, endovascular means are increasingly used, including chimney and periscope stent grafts, custom-made branched grafts for TEVAR, and in-situ laser fenestrations. [20][21][22] Squiers and coworkers compared outcomes of surgical debranching versus branched endografting in zone 2 TAA. 23 Both groups had 100% technical success and comparable 30-day mortality rates.…”

“…Notably, in another comparative study by Dueppers et al, the incidence of type I endoleak was higher and the technical success rate was lower in the endovascular group. 20 So far, no international consensus exists for the preferred LSA revascularization technique.…”

Long-Term Outcomes in Thoracic Endovascular Aortic Repair for Complicated Type B Aortic Dissection or Intramural Hematoma Depending on Proximal Landing Zone

“…The reason that significantly more patients required reinterventions when landing in zone 2 in the long-term could be that debranching procedures cannot always create a true HLZ, either through parallel grafts with gutterleaks or endoleaks, or through bypass or LSA transposition/bypass [ 16 , 17 ]. Generally, in many cases, a stump of the LSA remains, which could be considered a potential weak point for a type IA endoleak.…”