Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Abstract

Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.

Postendovascular thoracic aortic repair subclavian steal syndrome revealed by severe headache

“…Furthermore, Walker et al suggested that the majority of patients with SCSS have neurological symptoms actually due to other vascular lesions [24]. This can explain that the only patient who developed a neurologic complication is the only aged one from our four patients, with the possibility that the manifestation of the condition is probably dependent on the patency of the other cranial arteries which we should have checked as many teams do [25][26][27].…”

Successful 36 Months Result of Debranching TEVAR for Kommerell?s Diverticulm with the Aberrant Left Subclavian Artery

“…Although endovascular deployment of an occluder was a simple and safe method, we could not use these commercial devices in Japan. LSA coverage is often necessary to perform proximal seal in up to 40% of patients treated with TEVAR [4,5]. In our case we performed coil embolization to prevent type II endoleak and bypass between left common carotid artery and left subclavian artery with 6 mm ePTFE graft because of the hypo-plastic left vertebral artery and his dominant was the left.…”

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

“…A 2009 consensus from the Society of Vascular Surgery described the quality of the existing evidence on the performance of subclavian revascularisation in patients undergoing TEVAR as low (2C) [10]. A 2011 literature review from the European Association for Cardio-Thoracic Surgery, which resulted in the formulation of recommendation of prophylactic LSA revascularisation in elective patients, was based on numerous and heterogeneous series with small samples of patients [11]. Studies in support of routine preoperative LSA revascularisation show that the coverage of the LSA during TEVAR is associated with an increased risk of stroke, paraplegia and arm ischaemia.…”