Endograft Coverage of the Left Subclavian Artery During Repair of Traumatic Thoracic Aortic Injury May Be Associated With Significant Long-Term Morbidity

Abstract

Coverage of the left subclavian artery (LSCA) during thoracic endovascular aortic repair (TEVAR) has reportedly minimal long-term sequelae. As it is being used frequently in traumatic aortic transection, we hypothesized that trauma patients with LSCA coverage may often require secondary interventions because of ischemic complications. We conducted a single-institution, retrospective chart review of 82 patients who underwent TEVAR for blunt aortic transection (2004-2014). Patient demographics, comorbidities, concomitant injuries, details of the intervention, and thoracic aortic injury grade were collected. The outcomes included were immediate and long-term mortality rates, stroke, endoleak, device migration, lesion regression, open conversion, and reintervention rates secondary to morbidity associated with LSCA coverage. Statistical analysis included χ2 test, Fisher exact test, t-test, and Kaplan-Meier analysis. Eighty-two patients were treated with TEVAR with a technical success rate of 100% and mean follow-up of 2.3 ± 2.4 years. Fifty-eight patients had TEVAR without LSCA coverage, whereas 23 patients (28.0%) required either partial or complete coverage. The overall 30-day mortality rate was 7.3% (n = 6), mostly due to associated injuries. Mortality was similar between those with and without LSCA coverage (6.9% vs 8.7%; P = 1.0). Patients with LSCA coverage had significantly more hemodynamic instability on presentation than those who did not require LSCA coverage (43% vs 19%; P = .023). Adverse events and reinterventions associated with LSCA included one patient who died of concomitant trauma and one who died of an immediate, massive posterior stroke resultant from LSCA coverage. One patient was immediately revascularized because of previous left internal mammary artery-left anterior descending artery bypass, and one was revascularized because of immediate arm ischemia. Of the remaining 18 who were discharged without immediate revascularization, 5 required delayed revascularization for exertional arm pain or ischemia (Table). One-year survival rates were similar between groups (90.9% vs 91.3%; P = .976). In this study, the LSCA required coverage in approximately a quarter of patients during TEVAR for traumatic aortic injury to achieve an adequate proximal seal zone. This was associated with a significant incidence of late arm symptoms requiring revascularization, suggesting that it is not as benign a procedure as initially thought.TableMorbidity related to left subclavian artery (LSCA) coverage during thoracic endovascular aortic repair (TEVAR)Patient No.Age, yearsTime to intervention, daysInterventionMorbidity1690NoneDeath due to posterior stroke2790Left carotid-subclavian bypassProphylactic revascularization for prior LIMA-LAD3710Left subclavian stentImmediate arm ischemia441865Graft explantation and open bypassArm claudication522693Left subclavian transpositionSubclavian steal syndrome630164Left subclavian transpositionSubclavian steal syndrome718835Left carotid-subclavian bypassSubclavian steal syndrome837672Left subclavian stentArm claudicationLIMA-LAD, Left internal mammary artery-left anterior descending artery. Open table in a new tab