Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death

Chung, Jayer; Kasirajan, Karthikeshwar; Veeraswamy, Ravi K.; Dodson, Thomas F.; Salam, Atef A.; Chaikof, Elliot L.; Corriere, Matthew A.

doi:10.1016/j.jvs.2011.03.270

Cited by 87 publications

(70 citation statements)

References 21 publications

(37 reference statements)

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“…Of note, we did not find left subclavian artery coverage to be a significant risk factor for mortality, though it has previously been found to be predictive of both stroke and mortality. 24,26 Similarly, chronic obstructive pulmonary disease was not significant in bivariate analysis nor did it remain in the multivariable model, unlike prior findings. 15,17,24 Our results might suggest that these variables pertaining to more localized processes did not influence the outcome of mortality to the same extent in this sample population while risk factors frequently representative of systemic alterations in health status, such as elevated white blood cell count or increased red blood cell transfusion requirement, were found to be significant.…”

Section: Discussioncontrasting

confidence: 59%

Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair

Fang

Leshnower

et al. 2017

Journal of Vascular Surgery

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Objective Over the past decade, thoracic endovascular aortic repair (TEVAR) has increased as a treatment option for a variety of aortic pathologies. Despite this rise in the use of thoracic stent grafts, real-world outcomes from a robust, adjudicated, contemporary dataset have yet to be reported. Previous studies have shown peri-procedural mortality rates between 1.5%-9.5% and procedure-related stroke rates of 2.3%-8.2%. With advances in device engineering and increased physician experience, we hypothesized that the rates of these complications would be reduced in a more recent sample set. The purpose of this study was to determine current rates of mortality and stroke after TEVAR, identify risk factors that contribute to thirty-day mortality, and develop a simple scoring system that allows for risk stratification of patients undergoing TEVAR. Methods We examined the 30-day mortality rate following TEVAR using the 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing TEVAR for all aortic pathology were identified using procedure codes. Bivariate analyses were performed to evaluate the association of pre-, intra- and post-operative variables with 30-day mortality, followed by multivariable logistic analysis using pre-operative variables only, with P<.10 as criteria for model entry. The predictive logistic model was internally validated by cross validation. Variables included in the multivariable model were used to develop a risk score. Results Eight hundred twenty-six patients were included. The thirty-day mortality and stroke rate were 7.63% (n=63) and 4.5% (n= 37), respectively. In regression analysis, mortality was independently associated with age ≥80 years (odds ratio [OR] 2.32, 95% confidence interval [CI] 1.25-4.31), emergency case (OR 2.61, 95% CI 1.39-4.90), ASA classification >3 (OR 2.89, 95% CI 1.34-6.24), transfusion >4 units in the 72 hours prior to surgery (OR 2.86, 95% CI 1.30-6.28), pre-operative creatinine ≥1.8 mg/dL (OR 2.07, 95% CI 1.05-4.08), and pre-operative white blood cell count ≥12 × 109/L (OR 2.65, 95% CI 1.41-4.96). Incorporating these factors, a six-point risk score was generated and demonstrated high predictability for overall thirty-day mortality. Conclusions Recent data from a national, retrospective dataset demonstrate that high perioperative mortality and stroke rates have persisted over the last decade. The risk score derived from this dataset is simple and convenient and serves as a prognostic tool in the pre-operative risk stratification of patients being evaluated for thoracic endovascular aortic repair.

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Section: Discussioncontrasting

confidence: 59%

Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair

Fang

Leshnower

et al. 2017

Journal of Vascular Surgery

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“…For thoracic aortic pathologies with inadequate proximal sealing zones, TEVAR necessitates coverage of the left subclavian artery (LSA) and even the left common carotid artery (LCCA), in order to obtain good fixation of stent grafts. However, covering the origins of these arteries may induce some complications, such as left upper limb ischaemia, posterior circulation ischaemia or cerebral infarction [1, 2]. These considerations make the reconstruction of supra-arch branch vessels necessary for favourable outcomes.…”

Section: Introductionmentioning

confidence: 99%

The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair

Xue

Sun

Zheng

et al. 2014

European Journal of Cardio-Thoracic Surgery

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OBJECTIVESThe objective of the present study was to evaluate short- and mid-term outcomes of the left subclavian artery (LSA) chimney stent implantation (LSACSI) during thoracic endovascular aortic repair (TEVAR), and to summarize our experience with this technique.METHODSFrom June 2010 to September 2012, 59 patients (49 men; mean age of 57.4 ± 13.3 years, range from 26 to 83 years) who underwent TEVAR and LSACSI were enrolled. Patients suffered from Stanford type B aortic dissection (n = 27), penetrating aortic ulcer (n = 18), aortic arch aneurysm (n = 9), pseudoaneurysm of the aortic arch (n = 4) and proximal type I endoleak after TEVAR of aortic dissection (n = 1). Elective settings were performed in 72% and emergent in 38% of all patients. Follow-up was performed at postoperative 3 months, 6 months and yearly thereafter.RESULTSThe technical success rate was 98.3% (58/59), and 69 thoracic stent grafts were used. Sixty-two chimney stents, including 55 uncovered and 7 covered stents, were implanted in 59 LSAs. The overall immediate endoleak rate was 15.3% (9/59); type I endoleak was observed in 5 patients and type II in 4 patients. The difference in the immediate endoleak rate related to the anatomy between the outer and the inner curvature was statistically significant (35 vs 4%, P = 0.018). Chimney stent compression was observed in 3 patients and another stent was deployed inside the first one. Perioperative complications included stroke (3.4%, 2/59) and left upper limb ischaemia (1.7%, 1/59). The median follow-up period was 16.5 (range 1–39 months). The mortality rate during follow-up was 5.4% (3/56). Complications during follow-up included endoleak [overall, n = 8 (14.3%, 8/56); type I, n = 5; type II, n = 3], retrograde type A aortic dissection (n = 1), collapse (n = 3, 5.4%) or occlusion (n = 2, 3.6%) of the chimney stent.CONCLUSIONSShort- and mid-term results showed that it is feasible to preserve the patency of the LSA in TEVAR with the chimney technique for thoracic aortic pathologies close to the LSA. However, TEVAR combined with LSACSI was not advocated for lesions located at the outer curve of the aortic arch due to a high possibility of endoleak.

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“…However, TEVAR for aortic arch aneurysm involving the neck branches is limited at present, and the results are also controversial [8][9][10]. Current reports have indicated that the 30-day mortality of TEVAR with LSA coverage for distal arch aortic aneurysm is approximately 4-7 % [11][12][13], and it seems to be equivalent to open repair. In this study, the 30-day mortality was 2.5 % and 13 patients (10.7 %) presented complications.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes of Left Subclavian Artery Coverage on Morbidity and Mortality During Thoracic Endovascular Aortic Repair for Distal Arch Aneurysms

et al. 2015

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Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death

Abstract: LSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR. Further evidence is needed to determine whether procedural modifications, including LSA revascularization, reduce the incidence of stroke associated with TEVAR.

Cited by 87 publications

References 21 publications

Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair

Contemporary evaluation of mortality and stroke risk after thoracic endovascular aortic repair

The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair

Clinical Outcomes of Left Subclavian Artery Coverage on Morbidity and Mortality During Thoracic Endovascular Aortic Repair for Distal Arch Aneurysms

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