Abstract
To assess the outcome of stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR). Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between January 2010 and June 2019. Endpoints were perioperative cerebrovascular events and nerve injuries, patency and re-intervention due to the debranching, and mortality at 30 days and during follow-up. Forty-eight patients (median age 66 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%) patients, 11 (23%) of them in an emergent setting. There were 7 (15%) re-interventions within 30 days: 3 due to local hematoma, one for bypass occlusion, 2 for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. 30-day mortality was 2%; 1 patient died on the first postoperative day after emergency coronary artery bypass surgery and multiorgan failure. 4 (8%) patients suffered postoperative strokes; 3 occurred after simultaneous emergency procedures and none was fatal. There were 9 (19%) left neck nerve injuries in 8 patients, 5 patients had SCT and 3 CSB. During a median follow-up of 37.5 months (IQR 23-83) with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 90% and primary assisted patency 98% during follow-up. 8 patients died during follow-up, all of them with patent cervical debranching. Supraclavicular LSA revascularization for proximal landing zone extension in TEVAR is safe with an acceptable rate of early re-interventions. There is higher risk for perioperative stroke during concomitant emergency LSA revascularization and TEVAR. Left neck nerve injuries are common complications but resolve completely in vast majority of the cases during first postoperative year. During follow-up, excellent patency could be expected.
Highlights
Thoracic endovascular aortic repair (TEVAR) has become the first line therapy for different descending thoracic aortic pathologies.[1,2] In 40% of patients requiring TEVAR, the aortic pathology extends near the left subclavian artery (LSA).[3]
We included all patients between January 2010 and June 2019 who underwent elective or urgent supraclavicular LSA revascularization for proximal landing zone extension performed prior, simultaneously or subsequently to TEVAR with coverage of the LSA origin for the treatment of descending aortic pathologies
Demographic parameters and comorbidities are presented in Table I. 25 (52%) patients underwent carotid-subclavian bypass (CSB) and 23 (48%) subclavian to carotid transposition (SCT)
Summary
Thoracic endovascular aortic repair (TEVAR) has become the first line therapy for different descending thoracic aortic pathologies.[1,2] In 40% of patients requiring TEVAR, the aortic pathology extends near the left subclavian artery (LSA).[3]. LSA coverage without revascularization prior to or during TEVAR significantly increases the 30-day risk for stroke (up to 25%) and upper extremity ischemia (up to 15%).[4] The Society for Vascular Surgery has suggested routine preoperative LSA revascularization in patients undergoing elective TEVAR where proximal sealing requires LSA coverage, despite a very low level of evidence (GRADE 2, level C).[5] The LSA is most frequently revascularized via a supraclavicular access performing carotid-subclavian bypass (CSB) or subclavian to carotid transposition (SCT). LSA revascularization should be individualized based on anatomy, urgency and availability of surgical expertise.[5]
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