Invited commentary

Abstract

This single-center study is another piece of evidence in a growing wave of reports addressing important clinical outcomes after endovascular treatment of thoracic aortic pathology. In Table III, the authors specifically segregate outcomes in patients who did and did not have left subclavian artery revascularization, and the comparisons are striking, with a 28% risk of combined stroke, paraplegia, or death when the left subclavian artery was not revascularized compared with none when it was revascularized. Their analysis may be confounded by the nonrandomized design in which they more recently have routinely performed the subclavian revascularization, and they have certainly improved other components of their institutional systems. Further confounding may occur with emergency cases, when staged or simultaneous revascularization may not be possible. Taken together with other reports, these institutional experiences from centers of excellence with thoracic endovascular aortic repair are painting an impressive picture. In a recent meta-analysis of 51 eligible studies, sponsored by the Society for Vascular Surgery, the Mayo Clinic Knowledge and Encounter Research Unit found risks increased by odds ratios of 47.7 for arm ischemia, 10.8 for vertebrobasilar ischemia, 2.69 for spinal cord ischemia, and 2.58 for anterior circulation stroke with left subclavian coverage without revascularization compared with revascularization.1Rizvi A.Z. Murad M.H. Fairman R.M. Erwin P.J. Montori V.M. The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis.J Vasc Surg. 2009; 50: 1159-1169Abstract Full Text Full Text PDF PubMed Scopus (197) Google Scholar The clinical practice guidelines of the Society for Vascular Surgery “suggest” routine preoperative revascularization when the left subclavian artery is covered. They provide a stronger “recommend” routine revascularization in circumstances where collateral perfusion may be compromised.2Matsumura J.S. Lee W.A. Mitchell R.S. Farber M.A. Murad M.H. Lumsden A.B. et al.Management of the left subclavian artery with TEVAR: clinical practice guidelines of the Society for Vascular Surgery.J Vasc Surg. 2009; 50: 1155-1158Abstract Full Text Full Text PDF PubMed Scopus (304) Google Scholar Unfortunately, the evidence supporting these recommendations is very low quality, and there are no randomized data that provide stronger evidence for decisions being made today. It is not surprising there are worse outcomes with occlusion of a major aortic arch vessel compared with strategies that maintain antegrade flow in the left subclavian artery. Vertebral, internal thoracic, and thoracodorsal arteries can be major contributors of brain and spinal cord collateral blood flow. This St. George's Vascular Institute report is another contribution to the evidence favoring revascularization of the left subclavian artery. Outcomes of the endovascular management of aortic arch aneurysm: Implications for management of the left subclavian arteryJournal of Vascular SurgeryVol. 51Issue 6PreviewThis study was conducted to define the outcomes of treating aortic aneurysms involving the arch vessels with a hybrid approach using extra-anatomic reconstruction and endovascular repair with nonfenestrated stents. Full-Text PDF Open Archive