The strategies and outcomes of left subclavian artery revascularization during thoracic endovascular repair for type B aortic dissection

Abstract

This study was to analyze the outcomes of left subclavian artery (LSA) revascularization during thoracic endovascular repair (TEVAR) for type B aortic dissections (TBAD). From 2011 to 2017, TBAD patients who underwent LSA revascularization during TEVAR were enrolled. Technical success, endoleaks, mortality, complication, reintervention, and patency of target vessels were analyzed. 38 patients were included, 14 underwent carotid-subclavian bypass (CSB), and 24 underwent chimney graft (CG) implantation. Technical success rates were 92.9% and 100% in CSB and CG group. Eleven immediate type I endoleak (EL-I) was detected, including one from CSB group and ten from CG group. Three immediate type II endoleak (EL-II) was detected in CSB group. Perioperative complications showed no difference, but CSB group had longer intensive care unit (ICU) stay time. Median follow-up time was 26.2 months, and overall mortality was 14.3% and 0% in each group. Three EL-I and one EL-II underwent reintervention. All the LSA showed good patency, except one suffered from CG collapse. Both CSB and CG were feasible strategies to preserve the antegrade blood flow of LSA, and each strategy had its advantages and disadvantages. Based on our current experience, we preferred CG for high-risk patients. However, the evidence was still not strong enough, further well-designed studies are necessary to identify the criteria for LSA revascularization strategy during TEVAR.

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

“…6) In fact, there are only four studies exclusively comparing carotid-subclavian bypasses or subclavian-carotid transposition to chimney or periscope-sandwich grafts for LSA debranching. 8,[15][16][17] Table 4 demonstrates their results along with studies that examined either open or parallel graft-based LSA debranching only. 2,4,6,9,18) A former study from the reporting institution also described results of periscope-sandwich grafts for LSA debranching, but as only some of the patients were included into the presented cohort, their results were not used for comparison.…”

“…As in our study, statistical differences were neither detected for strokes, mortality, or reintervention rate. 8,[15][16][17] Nevertheless, all comparative studies reported more aortic reinterventions after parallel grafts than after open procedures. 8,[15][16][17] Our rate of 33% for parallel grafts is in line with Johnson et al, but others have reported much lower rates of 0.6%-12.5%.…”

“…8,[15][16][17] Nevertheless, all comparative studies reported more aortic reinterventions after parallel grafts than after open procedures. 8,[15][16][17] Our rate of 33% for parallel grafts is in line with Johnson et al, but others have reported much lower rates of 0.6%-12.5%. 8,15,17,18) Reasons for aortic reinterventions involved type IA and IB endoleaks, type II endoleak via non-occluded LSA branches, aortobronchial fistula, stent graft migration, and distal stent-induced new entry tear.…”

Reparación endovascular de aorta torácica con técnica de doble chimenea: una alternativa a la cirugía de arco aórtico posterior a la realización de Bentall-Bono en la disección aórtica tipo A

“…de manera ordinaria o electiva, siempre y cuando no se encuentre alguna contraindicación absoluta para no realizarlo, lo cual no se presentó en ningún paciente 6,7 . El seguimiento clínico después de la exclusión del ostium de la subclavia es estrecho, ahí se valora continuamente la presencia de claudicación, lesiones isquémicas o síndrome de robo subclavio y, en caso necesario, se realiza una revascularización, sin embargo, no ha sido necesario en ninguno de los pacientes de esta serie.…”

“…Dentro de la literatura, encontramos estudios donde se busca la preservación del flujo en la arteria subclavia 7,8 , e igualmente comparación entre la realización de bypass carótido-subclavio vs. manejo endovascular, sin encontrar diferencias significativas 9 , sin embargo, no hay mucha evidencia en el manejo con chimeneas del resto de los vasos supraaórticos 5,[10][11][12] . En la poca evidencia encontrada se observa que el manejo de zonas de anclaje más proximales se reserva a patología del arco aórtico y aorta ascendente 5,11,13,14 .…”