Open Versus Endovascular Left Subclavian Artery Revascularization Outcomes in Thoracic Endovascular Aortic Repair: A National Study

Abstract

Left subclavian artery (LSA) revascularization is recommended in patients undergoing elective thoracic endovascular aortic repair (TEVAR) with LSA coverage. However, the outcomes of open vs endovascular techniques for LSA revascularization remain poorly studied due to lack of high-quality evidence. The aim of this study is to use a large national database to compare the effects of open vs endovascular LSA revascularization for LSA coverage during TEVAR on the perioperative outcomes of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention. Patients who had undergone LSA revascularization for LSA coverage in the Vascular Quality Initiative TEVAR database between 2011 and 2022 were identified. Patients with no coverage of the LSA, no LSA revascularization after LSA coverage, conversion to open repair, proximal disease > zone 5, distal zone disease < zone 3, and genetic history of connective tissue disease were excluded. We divided our cohort into two groups: open and endovascular revascularization of LSA. Open LSA revascularization was defined as treatment with surgical bypass. Endovascular LSA revascularization was defined as treatment with stent, stent graft, chimney, scallop, stented scallop, fenestration, stented fenestration, fenestrated branch, side-arm branch, and iliac device. Outcomes were perioperative stroke, AI, SCI, 30-day mortality, and reintervention. A total of 3052 patients met our inclusion criteria. There were 2396 (78.5%) patients in the open LSA revascularization group and 656 (21.5%) patients in the endovascular LSA revascularization group. The results are summarized in the Table. When compared with open LSA revascularization, endovascular LSA revascularization showed no significant difference in the risk of stroke (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 0.8-1.5; P = .498), AI (aOR: 1.5, 95% CI: 0.7-3.1; P = .273), SCI (aOR: 0.7, 95% CI: 0.3-1.5; P = .337), and 30-day mortality (aOR: 1.3, 95% CI: 0.8-2.0; P = .254). Furthermore, there was no significant difference in the risk of reintervention (aOR: 0.7, 95% CI: 0.4-1.2; P = .166). In this analysis of Vascular Quality Initiative data, both open and endovascular LSA revascularization for LSA coverage during TEVAR were equally effective and durable with no significant difference in outcomes of stroke, AI, SCI, 30-day mortality, and reintervention. Thus, endovascular LSA revascularization is a viable alternative to open LSA revascularization that could reduce the need for staged carotid-subclavian bypass or transposition procedures. Further studies are warranted to compare the long-term outcomes of open vs endovascular LSA revascularization, in addition to comparing the outcomes of specific endovascular techniques to each other.TableMultivariate logistic regression of stroke, arm ischemia (AI), spinal cord ischemia (SCI), 30-day mortality, and reintervention outcomesOutcomeEndovascular LSA revascularization vs open LSA revascularizationaOR (95% CI) (reference = open LSA revascularization)P valueStroke1.1 (0.8-1.5).498AI1.5 (0.7-3.1).273SCI0.7 (0.3-1.5).33730-day mortality1.3 (0.8-2.0).254Reintervention0.7 (0.4-1.2).166aOR, adjusted odds ratio; CI, confidence interval; LSA, left subclavian artery. Open table in a new tab