Management of Anomalous Left Vertebral Artery During Open Total Arch Replacement

Abstract

BackgroundAn anomalous left vertebral artery (aLVA) can complicate aortic arch surgery. We examined the safety of various aLVA revascularization strategies during open total arch replacement. MethodsWe retrospectively evaluated 92 patients undergoing total arch replacement from January 2018 to May 2023 and identified 11 patients with aLVA. A comparison group (n = 31) with conventional 3-branched anatomy was selected by 3:1 matching on age, sex, circulatory arrest time, and operative mortality. Forty-two patients were selected for analysis. The primary outcome was perioperative stroke within 30 days. Secondary outcomes included spinal cord ischemia and long-term stroke. ResultsPatients with aLVA had an average age of 53 ±16 years. Indications included Stanford type A dissection (n = 4), chronic dissection with aneurysmal degeneration (n = 4), and primary aneurysmal disease (n = 3). The aLVA was reconstructed by transposition to the left carotid (n = 2) or subclavian (n = 8). In 1 case, partial zone 2 arch replacement was performed proximal to the aLVA and manipulation was not required. Total arch replacement with frozen elephant trunk was performed in 8 of 11 cases. No postoperative mortality was observed. One patient experienced transient postoperative stroke (9% vs 9%, P = 1.00). One patient received lumbar drain for suspected spinal cord ischemia (9% vs 7%, P = 0.59). One patient experienced stroke 6 months post operation. One-year patency of transposition was 100%. ConclusionsThe presence of aLVA does not impact outcomes of open arch surgery. Our strategy to preserve the aLVA may be preferable to simple ligation. We describe several safe and feasible approaches for reimplantation of this anomalous variant.