Results With a Selective Revascularization Strategy for Left Subclavian Artery Coverage During Thoracic Endovascular Aortic Repair

BackgroundThe management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate.Materials and methodsA retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm.ResultsOf the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A.ConclusionOur analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.

show abstract

“…This finding is in accordance with those of other studies in which selective LSA revascularisation was performed [7, 12, 13]. …”

Section: Discussionsupporting

confidence: 93%

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

Wojciechowski

Znaniecki

Bury

et al. 2014

Langenbecks Arch Surg

View full text Add to dashboard Cite

show abstract

“…Mean interval from initial dissection to TEVAR was 32 ± 44 months (range, 1 to 146 months). The left subclavian artery was partially or fully covered (zone 2 proximal landing zone [PLZ]) in 26 patients (81.3%), of whom 5 patients (19.2%) underwent adjunctive left carotid–subclavian bypass for previously described indications [19]. Cerebrospinal fluid drainage was used selectively in 3 patients (9.4%) for previously described indications [20].…”

Section: Resultsmentioning

confidence: 99%

Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Aortic Dissection

Hughes

Ganapathi

Keenan

et al. 2014

The Annals of Thoracic Surgery

Self Cite

View full text Add to dashboard Cite

Background Thoracic endovascular aortic repair (TEVAR) for chronic DeBakey IIIb dissection with associated descending aneurysm remains controversial. This study examines long-term results of TEVAR for this disorder including examination of anatomic features associated with TEVAR outcomes. Methods Between July 2005 and January 2013, 32 patients underwent TEVAR for chronic (>30 days) DeBakey IIIb dissection involving the descending thoracic aorta at a single institution and constituted the study cohort. Results The mean interval from dissection to TEVAR was 32 ± 44 months (range, 1 to 146 months). There were no 30-day or in-hospital deaths, strokes, or paraplegia. During a 54-month median follow-up, there were no aortic-related deaths. Significant thoracic aneurysm sac regression (>1 cm) in the intervened segment was observed in 89%. Thoracic remodeling was not correlated with the number of visceral vessels arising from the true lumen or the number or size of residual distal fenestrations; failure of thoracic remodeling was associated with fenestrations distal to the endograft(s) in the descending thoracic aorta, most often stent graft-induced new entry tears. Complete resolution of the thoracic and abdominal false lumen after TEVAR was observed in 15.6% (n = 5). All patients in this group had all visceral vessels arising from the true lumen and fewer than three residual distal fenestrations. Conclusions Thoracic endovascular aortic repair is effective for chronic DeBakey IIIb dissection with associated descending aneurysm, with excellent 30-day and long-term outcomes and significant aortic remodeling in the vast majority of patients. Thoracic remodeling does not appear dependent on distal anatomic characteristics of the true and false lumens, although care should be taken to cover all thoracic fenestrations and avoid creation of stent graft-induced new entry tears to ensure clinical success. Complete aortic remodeling was observed only in the setting of all visceral vessels off the true lumen with fewer than three residual distal fenestrations, and this would appear the ideal anatomy for TEVAR in this scenario.

show abstract

“…Again, conflicting data exist regarding stroke risk with addition of C-S BP/ST to TEVAR, and stroke after TEVAR is known to portend a particularly poor prognosis, with in-hospital mortality rates ranging from 5–33% 26–28 . Due to the concern of elevated stroke risk, some have endorsed a more selective LSA revascularization strategy 29, 30 .…”

Section: Discussionmentioning

confidence: 99%

Subclavian revascularization in the age of thoracic endovascular aortic repair and comparison of outcomes in patients with occlusive disease

Scali

Chang

Pape

et al. 2013

Journal of Vascular Surgery

View full text Add to dashboard Cite

OBJECTIVE Open surgical revascularization for subclavian artery occlusive disease (OD) has largely been supplanted by endovascular treatment despite the excellent long-term patency of bypass. The indications for carotid-subclavian bypass (CSB) and subclavian transposition (ST) have been recently expanded with the widespread application of thoracic endovascular aortic repair (TEVAR), primarily to augment proximal landing zones or treat endovascular failures. This study was performed to determine the outcomes of patients undergoing C-S BP/ST in the context of contemporary endovascular therapies and evolving indications. METHODS A prospective database including all procedures performed at a single institution from 2002–2012 was retrospectively queried for patients who have undergone subclavian revascularization for either TEVAR or OD indications. Patient demographics and perioperative outcomes were recorded. Patency was determined by computed tomographic angiography in the TEVAR group, while non-invasive studies were used for the OD patients. Life table methods were used to estimate patency, re-intervention and survival. RESULTS A total of 139 procedures were identified, with 101 performed for TEVAR, and 38 for OD. All TEVAR patients underwent CSB/ST to augment landing zones (preoperative 49%; intraoperative 41%), treat arm ischemia (postoperative, 8%), or for internal mammary artery salvage (2%). OD patients had a variety of indications [failed stent/arm fatigue, 49%; asymptomatic, >80% internal carotid stenosis with concurrent subclavian occlusion, 18%; symptomatic cerebrovascular occlusive disease (CVOD), 13%; redo bypass, 8%; and coronary-subclavian steal, 5%]. There were no significant differences in postoperative stroke and death, primary patency, or freedom from reintervention. The 30-day postoperative stroke, death, and combined stroke/death were 10.8%, 5.8%, and 13.7% for the entire cohort; 8.9%, 7.1%, and 12.9% in TEVAR patients and 15.8%, 2.6%, and 15.8% in OD patients, r espectively. One and 3-year primary patencies of TEVAR and OD patients were 94%, 94% and 93%, 73%, respectively. There was no difference in survival between the groups, with 1 and 5-year survival estimated to be 88% and 76%, respectively. CONCLUSION In this contemporary series of CSB/ST performed for TEVAR and OD indications, stroke risk may be higher than previously reported in historical series. In TEVAR patients, this may be attributed to procedural complexity of the TEVAR in patients requiring subclavian revascularization. In OD patients, this is likely due to the changing patient population who require more frequent concomitant carotid interventions. Despite the short-term morbidity, excellent bypass durability and equivalent long-term patient survival can be anticipated.

show abstract

Results With a Selective Revascularization Strategy for Left Subclavian Artery Coverage During Thoracic Endovascular Aortic Repair

Cited by 85 publications

References 16 publications

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

Thoracic Endovascular Aortic Repair for Chronic DeBakey IIIb Aortic Dissection

Subclavian revascularization in the age of thoracic endovascular aortic repair and comparison of outcomes in patients with occlusive disease

Contact Info

Product

Resources

About