The Society for Vascular Surgery Practice Guidelines: Management of the left subclavian artery with thoracic endovascular aortic repair

Abstract

The Society for Vascular Surgery pursued development of clinical practice guidelines for the management of the left subclavian artery with thoracic endovascular aortic repair (TEVAR). In formulating clinical practice guidelines, the society selected a panel of experts and conducted a systematic review and meta-analysis of the literature. They used the grading of recommendations assessment, development, and evaluation (GRADE) method to develop and present their recommendations. The overall quality of evidence was very low. The committee issued three recommendations. Recommendation 1: In patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence (GRADE 2, level C). Recommendation 2: In selected patients who have an anatomy that compromises perfusion to critical organs, routine preoperative LSA revascularization is strongly recommended, despite the very low-quality evidence (GRADE 1, level C). Recommendation 3: In patients who need urgent TEVAR for life-threatening acute aortic syndromes where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest that revascularization should be individualized and addressed expectantly on the basis of anatomy, urgency, and availability of surgical expertise (GRADE 2, level C).

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…44e46, 49,50 In the acute setting, revascularisation should be performed based on the patient's anatomy (left mammary to coronary bypass, or dominant cerebral blood supply from the left vertebral artery) during emergency repair of the DTA (see also Sections 3.1 and 3.3).…”

“…129 In cases in which the LSA is to be covered, prior revascularisation of the LSA in the emergency setting is recommended in patients with a left internal mammary artery to coronary artery bypass, or in those with a clearly dominant left vertebral artery. In all other emergency patients, LSA coverage without revascularisation can be performed 49,129 (see also Section 2.4.4.). In cases with challenging distal thoracic aortic anatomy, the CA can be selectively covered.…”

“…47 Arm ischaemia, paraparesis, and paraplegia may occur from LSA or intercostal artery occlusion, which may require revascularisation. 49,50 (see Section 2.4.4). Other complications (device or procedure related) can include aortic rupture during deployment, angulation, migration, or collapse of the stent graft, false aneurysm formation at the proximal or distal end of the stent graft, graft erosion, or stent frame fracture.…”

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques

“…The proximal seal zone beyond the left subclavian artery (LSA) is estimated to be of inadequate length in 26-40% of patients with disease of the descending thoracic aorta. (7,8) In these cases, achievement of an adequate proximal seal zone for endograft requires coverage of the LSA. Coverage of the LSA is associated with increased risk of stroke, spinal cord ischemia, and upper extremity ischemia.…”

Endovascular repair in acute traumatic aortic transection: a case report

“…Ancak özellikle sağ vertebral arterin dominant olduğu durumlarda proflaktik olarak revaskülarizasyonu önerenler de vardır. [3] Bizim hastamızda sol subklaviyen arter revaskülarize edilmemiş, ameliyattan sonra bununla ilgili herhangi bir komplikasyon gelişmemiştir.…”