Cervical Debranching in the Endovascular Era: A Single-center Experience

Abstract

Introduction - Debranching of supra-aortic arterial trunks is a common practice nowadays as part of either a hybrid treatment of aortic arch pathologies or as treatment of pathologies of the supra-aortic vessels themselves. Whereas the endovascular procedures of the aortic arch are continually and sufficiently studied, debranching techniques remain not adequately studied yet. This study focuses on supra-aortic debranching procedures and their outcomes, regardless of the indication for operation. Methods - A retrospective single-centre study of all consecutive patients that underwent cervical debranching procedures either as part of a hybrid endovascular treatment of the arch or due to pathology of the supra-aortic vessels themselves. Results - Between January 2010 and October 2017, a total of 230 patients underwent 241 cervical debranching procedures in our tertiary center. The mean age was 66.9±11.4 years (68.7% males; 158/230), mean BMI 26±5 and in 87.4% of the cases (177/207 patients) the operation was performed as part of a hybrid endovascular aortic treatment. In the large majority of cases a sole carotido-subclavian bypass was performed (184/241 patients, 76.3%), followed by transposition of the subclavian artery to the ipsilateral carotid (20/241; 8.3%), sole interposition of the carotid artery in 2 cases (0.9%) and a combination of procedures in 35 patients (14.5%). In total, 62/241 cervical revascularizations (25.7%) presented early postoperative local complications. Thirty cases (12.4%) presented local bleeding, with twenty-seven cases requiring a re-intervention (11.2%). Twenty-three patients (9.5%) presented with local peripheral neurological damage postoperatively. Ten patients (4.1%) developed a chylous fistula and six (2.5%) presented a local wound infection. One patient (0.4%) developed a bypass-graft infection. The 30-day mortality rate was 7.9% (19/241) and the total major stroke incidence was 5% (12/241). Whether the hybrid procedures were undertaken in a one-stage (with simultaneous TEVAR and cervical debranching) or two-stage fashion appeared to have a significant impact on early mortality (30-day mortality in patients that underwent simultaneous TEVAR and debranching 9/60; 15% vs. 30-day mortality after sole debranching or two-stage hybrid procedures 10/181; 5.5%, p=0.026) as well as major stroke incidence (major stroke in patients with sole debranching 4/181; 2.2% vs. major stroke in patients with simultaneous TEVAR and debranching 8/60; 13.3%, p<0.01). The primary cumulative graft patency during the follow-up was at 97.9% (236/241). The secondary patency during the follow-up remained at 100%. Conclusion - Cervical debranching procedures is a safe and durable surgical option for open revascularisation of supra-aortic vessels covered by a stentgraft. The current results show good patency rates but also a significant rate of local complications. Further studies should focus on further identifying patients at high risk of complications that would eventually benefit from an endovascular revascularisation of the target vessels.