Left Subclavian Artery Coverage Research Articles

Endovascular treatment of traumatic thoracic aortic lesions: a systematic review and meta-analysis.

To provide an overview of the experience of endovascular treatment for traumatic thoracic aortic lesions (TTAL). Thoracic aortic injury secondary to high-energy chest trauma constitutes an emergency situation with potentially devastating outcome. In the present time, the majority of patients are treated with thoracic endovascular aortic repair. The aim of this study was to provide a systematic overview of endovascular aortic repair in patients with TTAL with special attention to perioperative mortality, paraplegia, stroke, influence of left subclavian artery (LSA) coverage herein, and long-term stent-related complications. PubMed and Embase were searched for studies describing endovascular treatment of TTAL in the period between January 1st, 2000 and January 30th, 2016. The methodological quality of articles was assessed using the MINORS score and PRISMA guidelines. Data on early mortality, perioperative complications, and long-term stent-related complications were extracted. A total of 2005 reports were screened, and 74 publications were finally included in the analysis describing treatment of 1882 patients. Early mortality rate, paraplegia rate, and stroke rate were 7.5%, 0.4%, and 1.5%, respectively. LSA coverage did not increase the risk of stroke. The severity of injuries had a positive association on early mortality. Late stent related mortality and morbidity were uncommon. TTAL can be treated endovascularly with low mortality and (neurological) morbidity. LSA coverage does not increase the risk of neurological complications but is associated with a moderate risk of left arm ischemia. Long-term stent-related complications are rare, but the available data is limited.

Management of the vertebral artery during thoracic endovascular aortic repair with coverage of the left subclavian artery

The application of thoracic endovascular aortic repair (TEVAR), a minimally invasive operation, in the aortic arch has been a challenge of cardiovascular surgery in recent years. This study aimed to investigate management of the vertebral artery with coverage of the left subclavian artery (LSA) during TEVAR. From January 2007 to September 2014 in the Department of Cardiothoracic Surgery at Wuhan General Hospital of Guangzhou Military Region, 160 patients underwent LSA closure or partial coverage during TEVAR of an aortic lesion near the LSA. The vertebral artery treatment, the reason for the surgical approach selection, and the prognosis were analyzed. In 94 patients with partial LSA coverage during TEVAR, no treatment was provided for the vertebral arteries, revealing blood flow of the left vertebral artery forward into the skull after surgery. For 66 patients with full LSA coverage (closure) during TEVAR, right carotid artery-left common carotid artery bypass surgery was performed before TEVAR in ten patients, without any treatment for the vertebral artery, showing reverse blood flow of the left vertebral artery after surgery. Left common carotid artery-LSA bypass surgery was performed before TEVAR in four patients; right common carotid artery-left common carotid artery-LSA bypass surgery was performed before TEVAR in three cases, and 6 out of these 7 patients underwent proximal LSA ligation, showing no obvious blood flow in the left vertebral artery. The closure of the LSA aortic arch opening using an occluder was performed in one patient, preserving the forward blood flow in the left vertebral artery. Among the 160 patients in this study, postoperative recurrent laryngeal nerve injury occurred in one patient after right common carotid artery-left common carotid artery-LSA bypass surgery, and the remaining 159 patients had no significant severe complications or death within 1 postoperative month. Appropriate management of the aortic arch branch vessels may expand the application of TEVAR to the aortic arch and reduce complications, especially for high-risk patients who have a difficult time tolerating thoracotomy.

Long-term outcomes of thoracic endovascular aortic repair: A single institution's 11-year experience.

Thoracic endovascular aortic repair (TEVAR) has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown. All patients who underwent TEVAR from December 2004 to October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2 to 132 months and was obtained from clinic notes and imaging reports. A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were men. Median age, Injury Severity Score, and Trauma and Injury Severity Score was 47 (19.7), 38 (13.5), 0. 8 (0.34). Injuries included 2% grade II, 90% grade III, and 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57%, whereas TEVAR-related complication rate was 9.1%: four typ 1a endoleaks, two typ 2, and two typ 3. Of the typ 1 endoleaks, all required reoperation, whereas all types 2 and 3 endoleaks resolved on subsequent imaging. The left subclavian artery (LSCA) was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of postoperative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in two patients before LSCA coverage at index operation. Eighty-seven percent of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intraoperatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imagings occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, and 5 years from operation was 62.1%, 25%, 13.6%, respectively. TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown; however, these data suggest that it may be at least comparable to open repair. Prognostic/epidemiologic study, level IV; therapeutic study, level V.

Incidence of Stroke Following Thoracic Endovascular Aortic Repair for Descending Aortic Aneurysm: A Systematic Review of the Literature with Meta-analysis

Stroke is an increasingly recognised complication following thoracic endovascular aortic repair (TEVAR). The aim of this study was to systematically synthesise the published data on perioperative stroke incidence during TEVAR for patients with descending thoracic aneurysmal disease and to assess the impact of left subclavian artery (LSA) coverage on stroke incidence. A systematic review of English and German articles on perioperative (in-hospital or 30 day) stroke incidence following TEVAR for descending aortic aneurysm was performed, including studies with ≥50 cases, using MEDLINE and EMBASE (2005-2015). The pooled prevalence of perioperative stroke with 95% CI was estimated using random effect analysis. Heterogeneity was examined using I2 statistic. Of 215 studies identified, 10 were considered suitable for inclusion. The included studies enrolled a total of 2594 persons (61% male) between 1997 and 2014 with a mean weighted age of 71.8 (95% CI 71.1-73.6) years. The pooled prevalence for stroke was 4.1% (95% CI 2.9-5.5) with moderate heterogeneity between studies (I2 = 49.8%, P = .04). Five studies reported stroke incidences stratified by the management of the LSA, that is uncovered versus covered and revascularised versus covered and not-revascularised. In cases where the LSA remained uncovered, the pooled stroke incidence was 3.2% (95% CI 1.0-6.5). There was, however, an indication that stroke incidence increased following LSA coverage, to 5.3% (95% CI 2.6-8.6) in those with a revascularisation and 8.0% (95% CI 4.1-12.9) in those without revascularisation. Stroke incidence is an important morbidity after TEVAR, and probably increases if the LSA is covered during the procedure, particularly in those without revascularisation.

Left subclavian artery revascularization in zone 2 thoracic endovascular aortic repair is associated with lower stroke risk across all aortic diseases

BackgroundThe best management strategy for the left subclavian artery (LSA) in pathologic processes of the aorta requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSA coverage with or without revascularization as well as the different means of LSA revascularization. MethodsA retrospective chart review was conducted of patients with any aortic diseases who underwent zone 2 TEVAR deployment from 2007 to 2014. Primary end points included 30-day stroke and 30-day spinal cord injury (SCI). Secondary end points were 30-day procedure-related reintervention, freedom from aorta-related reintervention, aorta-related mortality, and all-cause mortality. ResultsWe identified 96 patients with zone 2 TEVAR who met our inclusion criteria. The mean age of the patients was 62 years, with 61.5% male. Diseases included acute aortic dissections (n = 25), chronic aortic dissection with aneurysmal degeneration (n = 22), primary aortic aneurysms (n = 21), penetrating aortic ulcers/intramural hematomas (n = 17), and traumatic aortic injuries (n = 11). Strategies for the LSA included coverage with revascularization (n = 54) or without revascularization (n = 42). Methods of LSA revascularization included laser fenestration with stenting (n = 33) and surgical revascularization: transposition (n = 10) or bypass (n = 11). Of the 54 patients with LSA revascularization, 44 (81.5%) underwent LSA intervention at the time of TEVAR and 10 (18.5%) at a mean time of 33 days before TEVAR (range, 4-63 days). For the entire cohort, the overall incidence of 30-day stroke was 7.3%; of 30-day SCI, 2.1%; and of procedure-related reintervention, 5.2%. At a mean follow-up of 24 months (range, 1-79 months), aorta-related reintervention was 15.6%, aorta-related mortality was 12.5%, and all-cause mortality was 29.2%. The 30-day stroke rate was highest for LSA coverage without revascularization (6/42 [14.3%]) compared with any form of LSA revascularization (1/54 [1.9%]; P = .020), with no difference between LSA interventions done synchronously with TEVAR (1/44 [2.3%]) vs metachronously with TEVAR (0/10 [0%]; P = .63). There was no significant difference in 30-day SCI in LSA coverage without revascularization (2/42 [4.8%]) vs with revascularization (0/54 [0%]; P = .11). There was no difference in aorta-related reintervention, aorta-related mortality, or all-cause mortality in coverage without revascularization (5/42 [11.9%], 6/42 [14.3%], and 14/42 [33.3%]) vs with revascularization (10/54 [18.5%; P = .376], 6/54 [11.1%; P = .641], and 14/54 [25.9%; P = .43], respectively). After univariate and multivariable analysis, we identified LSA coverage without revascularization as associated with a higher rate of 30-day stroke (hazard ratio, 17.2; 95% confidence interval, 1.3-220.4; P = .029). ConclusionsOur study suggests that coverage of the LSA without revascularization increases the risk of stroke and possibly SCI.

Progress on coverage and reconstruction of left subclavian artery in thoracic endovascular aortic repair

Coverage of the left subclavian artery is often necessary to establish an adequate landing zone in patients undergoing thoracic endovascular aortic repair, which can avoids endoleaks that contribute the important aspect of technical success of thoracic endovascular aortic repair. However, there have been controversial whether the routine revascularization of left subclavian artery benefits in preventing the complications in perioperative, like cerebrovascular accident, and which approach of revascularization should be taken for more advantages. In this review, the disputes have been discussed between the routine revascularization and selective revascularization of left subclavian artery based on clinic research published in recent years, and also introduce the progress in open surgery and endovascular technique of left subclavian artery revascularization. Key words: Aortic aneurysm, thoracic; Left subclavian artery; Endovascular repair; Postoperative complication; Review

Simultaneous Endovascular Repair for Thoracic and Abdominal Aortic Pathologies: Early and Midterm Results

To analyze information from a single clinical center, evaluating early and midterm results of simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) for coexisting thoracic and abdominal aortic pathologies. From January 2005 to December 2014, 13 patients (8 men, 5 women; mean age, 75.3years; range, 69-82years) with concomitant thoracic and abdominal aortic disease (aneurysms, type B dissection, penetrating aortic ulcers) were treated with simultaneous TEVAR and EVAR. All patients had significant comorbidities. No preoperative cerebrospinal fluid drainage was performed. The follow-up rate was 100% during a period of 36months (range, 1-60months). Technical success was achieved in all 13 patients, including deliberate partial or total coverage of the left subclavian artery in 3 patients, coverage of both internal iliac arteries in 1 patient, and coverage of left subclavian artery and unilateral internal iliac artery in 1 patient. The average procedural time was 160min (range, 120-200min). Mean blood loss was 140mL (range, 100-250mL). Four types of commercially available stent grafts (SGs) wereused. The lengths of the thoracic SGs were 150-200cm. Overall survival was 92.3% at 1- and 3-year follow-ups. None of the patients developed stroke or paralysis. The average hospital stay was 9days (range, 7-12days). No patients developed endoleak or SG migration. Combined TEVAR and EVAR can be performed successfully with minimal morbidity and mortality. When anatomically feasible, simultaneous TEVAR and EVAR is a viable alternative to staged or hybrid repair.

Functional Assessment and Evaluation of Outcome After Endovascular Therapy With Coverage of the Left Subclavian Artery in Case of Blunt Thoracic Aortic Injury

Patients suffering blunt thoracic aortic injury (BTAI) can be treated by use of thoracic endovascular aortic repair (TEVAR). In this setting, the coverage of the left subclavian artery (LSA) is frequently necessary. Nevertheless, the functionality of the upper left extremity after TEVAR had been rarely analyzed. Thus, this study intends to underline the safety of TEVAR as well as to determine the functionality of the left arm after coverage of the LSA. All patients suffering from BTAI treated by endovascular means in 3 centers (Aachen [Germany], Maastricht [Netherlands], and Innsbruck [Austria]) between 1996 and2009 were retrospectively analyzed. The safety of the procedure had been assessedby the morbidity and mortality rate. The mid-term functional status of the upper left extremity was evaluated by using the DASH score (disabilities of the arm shoulder and hand). Forty-six patients (40 male, 6 female), mean age 39.4 ± 16.9years suffered from BTAI caused by traffic accident (n=31 [67.39%]), by skiing injury (n=8 [17.39%]), and by fall (n=7 [15.21%]). All patients underwent TEVAR, the technical success rate was 100%; 1 carotid-carotid subclavian bypass implantation was necessary. LSA coverage was performed in 76% (35/46) of the cases. Total complication rate was 17.3% (8/46); the endoleak rate was 8.6% (4/46) (2 × Ib, 1 × IIa, 1 × IV). Further complications were bypass andendograft occlusion. The postoperative mortality rate was 6% (3/46), the DASH score was completed in 65% (30/46). The study population reached a mean value of 17±20, which is comparable to a nonharmed reference group (10.10±14.68). A significant correlation between the DASH score and patients age could be demonstrated (2-sided P value: 0.0213). Endovascular therapy of BTAI revealed a good primary success rate. An adequate mid-term functional status of the upper left extremity could be assessed in comparison to a nonharmed reference group.

Analysis of Risk Factors for Early Type I Endoleaks After Thoracic Endovascular Aneurysm Repair

Purpose: To evaluate risk factors for early (<30 days) type I endoleak following thoracic endovascular aortic repair (TEVAR). Methods: A retrospective study was conducted of 439 consecutive patients (mean age 74.0±10.0 years; 333 men) who underwent TEVAR at a single center between June 2006 and June 2013. Pathologies included 237 aortic arch aneurysms and 202 descending thoracic aortic aneurysms (dTAA). Maximum TAA diameter was 63.6±13.7 mm. Among the distal aortic arch aneurysms, 124 required coverage of the left subclavian artery (LSA), while the remaining 113 arch aneurysms had debranching (n=40), the chimney technique (n=52), and a branched stent-graft (n=13). Eight patients with dilatation of the ascending aorta underwent arch replacement with elephant trunk prior to TEVAR. Predictive factors for type I endoleak were explored in univariate analysis and examined for each outcome using logistic regression models; results are given as the odds ratio (OR) and 95% confidence interval (CI). Results: Among 439 TEVAR cases, 37 (8.4%) had type I endoleaks on imaging at 1 month; 31 were in the 237 arch cases (13.1%). Endoleak investigation by site indicated a low incidence (3.0%) for dTAAs and markedly low (1.4%) in zone 4. Significantly more endoleaks were observed in zones 0–2 than in zone 4 (p<0.001). On univariate analysis, significant associations were found between endoleak and LSA coverage (OR 5.8, 95% CI 2.4 to 14.4, p<0.001), operative time ≥240 minutes (OR 3.7, 95% CI 1.5 to 6.2, p=0.002), and ≥270 mL of contrast (OR 2.8, 95% CI 1.4 to 5.8, p=0.004). Among the aortic branch reconstruction procedures, the chimney technique was the only maneuver associated with a significant risk of endoleak (OR 5.3, 95% CI 2.3 to 11.2, p<0.001). Arch state was not correlated with endoleaks, but ≥38-mm proximal neck diameter (OR 3.6, 95% CI 1.2 to 10.8, p=0.023), stent-graft diameter ≥40 mm (OR 9.9, 95% CI 1.4 to 30.5, p=0.015), and excessively oversized (≥14%) stent-grafts (OR 3.5, 95% CI 1.2 to 10.3, p=0.020) were; the proximal neck length was not correlated with endoleaks if a proximal neck length >10 mm can be secured. Conclusion: Risks for early type I endoleaks after TEVAR for aneurysm were landing zone 0–2, LSA coverage, large proximal neck and stent-graft diameters, excessive oversizing, and the use of the chimney technique.

Outcomes of Left Subclavian Artery Transposition for Hybrid Aortic Arch Debranching

The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching. Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± 16years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% (n=13) were never revascularized, and the remaining patients underwent LSA revascularization (n=55; 80.8%). Revascularization was achieved by LSA-carotid transposition via a medial approach in 81.8% (n=45) and a lateral approach in 18.2% (n=10). The indication for TEVAR was aneurysmal disease in 30.9% (n=17), dissection in 29% (n=16; acute, n=5), traumatic aortic injury in 21.8% (n=12), pseudoaneurysm in 10.9% (n=6), aortobronchial fistula in 5.5% (n=3), and penetrating atherosclerotic ulcer in 1.9% (n=1). Elective cases accounted for 52.7% (n=29). Follow-up computed tomography scans were performed at 1week, 3 and 6months, and annually thereafter. LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients (n=4). Hematoma requiring surgical drainage was observed in 3.6% of patients (n=2). Lymph leak requiring revision surgery was observed in 1.8% of patients (n=1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher (P=0.03) in patients with LSA transposition via a lateral approach (20%; n=2) when compared to patients with LSA revascularization via a medial approach (11.1%; n=5). After a mean follow-up of 31.5months (range, 2-171months), the patency of the LSA revascularization was maintained in all patients. During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.

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

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

Early outcomes after left subclavian artery revascularisation in association with thoracic endovascular aortic repair.

Approximately 40-50% of patients undergoing thoracic endovascular aortic repair require left subclavian artery coverage for adequate proximal landing zone. Many of these patients undergo left subclavian artery revascularisation. However, outcomes data for left subclavian artery revascularisation in the context of thoracic endovascular aortic repair remain limited. In this study, 70 left subclavian artery revascularisation procedures, performed on thoracic endovascular aortic repair patients at a tertiary hospital, were retrospectively reviewed. Particular emphasis was placed on revascularisation-related outcomes during staging interval between revascularisation and thoracic endovascular aortic repair. Forty-six (66%) carotid-subclavian bypass, 17 (24%) carotid-carotid-subclavian bypass and 7 (10%) aorto-inominate-carotid-subclavian bypass procedures were performed. There were no strokes or mortalities following left subclavian artery revascularisation procedures alone. Three (10%) minor complications occurred including a seroma, a haematoma and a temporary neuropraxia. Separation of complications following left subclavian artery revascularisation from those of the associated thoracic endovascular aortic repair can be difficult. Early outcomes data from patients who underwent left subclavian artery revascularisation in isolation indicate that the procedure is safe with low complication rates.

Meta-analysis of Left Subclavian Artery Coverage With and Without Revascularization in Thoracic Endovascular Aortic Repair

Purpose: To examine the role of left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) with LSA coverage. Methods: A systematic search was conducted to identify all studies providing comparative outcomes with or without LSA revascularization for LSA occlusion during TEVAR. The search included MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry, ClinicalTrials.gov , ISRCTN Register, and bibliographic reference lists. The primary outcome parameters were perioperative stroke, spinal cord ischemia (SCI), and mortality. Combined overall effect sizes were calculated using fixed effect or random effects models; results are reported as the odds ratio (OR) and 95% confidence interval (CI). Results: Five observational studies reporting a total of 1161 patients were identified; 444 patients underwent LSA revascularization and the remaining 717 patients did not. LSA revascularization was associated with a similar risk of stroke (OR 0.70, 95% CI 0.43 to 1.14, p=0.15), SCI (OR 0.56, 95% CI 0.28 to 1.10, p=0.09), and mortality (OR 0.87, 95% CI 0.55 to 1.39, p=0.56) compared with no LSA revascularization. Conclusion: LSA revascularization was not found to significantly reduce neurologic complications or mortality in patients undergoing TEVAR with coverage of the LSA origin. Randomized clinical trials are required to elucidate the role of routine or selective LSA revascularization in these cases.

Single-center experience with simultaneous thoracic endovascular aortic repair and abdominal endovascular aneurysm repair.

Objective To evaluate the efficacy and outcomes of simultaneous thoracic endovascular aortic repair (TEVAR) and abdominal endovascular aneurysm repair (EVAR). Methods A total of 21 patients (20 men; mean 65 ± 7 years, range 54-77) underwent simultaneous TEVAR and EVAR between September 2010 and June 2015 at a single center were retrospectively reviewed. All patients had concomitant thoracic pathologies (aneurysm, penetrating aortic ulcer, intramural hematoma, or dissection) and abdominal aortic aneurysm. The abdominal aneurysms diameters ranged from 5.9 cm to 10 cm. Thoracic lesions in 17 patients were complicated with acute aortic syndrome, and the remainders had indications for simultaneous repair. All patients were followed up postoperative at 1 month, 6 months, and yearly thereafter. Technique success, procedure-related complications were evaluated. Results All patients received local anesthesia, perioperative relative high arterial pressure (above 130/80 mmHg) maintenance, and prophylactic high-dose corticosteroid. The technical success rate was 100%. Average procedural time was 157.6 ± 45.6 min. The length of thoracic coverage was 20.4 ± 4.7 cm (range 15-27). Two patients required left subclavian artery coverage during TEVAR and two patients required lowest renal artery coverage during EVAR. Chimney stents were deployed simultaneously. Patients were followed between 2 and 59 months postoperatively. No patients developed acute cardiopulmonary complications and contrast-induced nephropathy. Two patients developed transient lower extremity weakness that resolved with blood pressure elevation, cerebrospinal fluid drainage, and intravenous drips of high-dose corticosteroid. The average hospital stay was 10.7 ± 7.9 days (range 4-30). During follow-up, one patient died of aneurysm rupture at postoperative 6 months, two patients developed type Ib endoleak at 9 months and 48 months respectively, one was successfully sealed with iliac stent-graft extension, the other received conservative treatment and is symptom free till now. Conclusion Combined TEVAR and EVAR can be performed safely with minimal morbidity and mortality. When anatomically feasible, simultaneous TEVAR and EVAR can be considered as an acceptable alternative for multilevel aortic diseases.

Long-Term Experience of Endovascular Repair for Thoracic Aortic Aneurysms and Dissections

To report the long-term results of thoracic endovascular aortic repair (TEVAR) in both elective and emergency cases of thoracic aortic aneurysm (TAA) and type B dissection. A prospective single-center study of 78 TEVAR patients treated between February 1998 and February 2013. Stent-graft implantation was performed in 51 (65%) patients for TAA (43 elective and 8 emergency cases) and in 27 (35%) patients for type B dissection (11 elective and 16 emergency cases). Short- and long-term results were evaluated, and a subgroup of patients with left subclavian artery (LSA) coverage was also analyzed. The patients were followed for a mean of 55 months (1-160 months). The technical success rate was 81% and 30-day mortality 6.4% (n = 5). The stroke rate was 7.7% (n = 6) and permanent paraparesis 2.6% (n = 2). In follow-up, there were 28 (36%) primary (15 type I and 13 type II) and 10 secondary endoleaks (8 type I and 2 type II). Multivariate analysis showed no significant predictive factors for developing a type I endoleak. Secondary interventions were required in 24% of the patients. There was 1 late thoracic aortic rupture and 1 late conversion (1.3%). Patients with LSA coverage had a higher incidence of stroke (12.5% vs 4.3%, P = .18) and paraparesis (3.1% vs 2.2%, P = .79) compared to those without LSA coverage, although this difference was not statistically significant. Stroke rates were significantly higher in patients treated in an emergency setting (P = .048). Thoracic endovascular aortic repair is a relatively safe and effective therapy for different aortic pathologies with good long-term success. The risk of stroke and paraparesis is notable whether the LSA is covered, and strokes clearly accumulate in the emergency setting. A type I endoleak is the most common complication, but there are no predictive factors for its development.

Revascularisation of the left subclavian artery for thoracic endovascular aortic repair.

Controversy exists as to whether revascularisation of the left subclavian artery (LSA) confers improved outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR). Even though preemptive revascularisation of the LSA has theoretical advantages, including a reduced risk of ischaemic damage to vital organs, such as the brain and the spinal cord, it is not without risks. Current practice guidelines recommend routine revascularisation of the LSA in patients undergoing elective TEVAR where achievement of a proximal seal necessitates coverage of the LSA, and in patients who have an anatomy that compromises perfusion to critical organs. However, this recommendation was based on very low-quality evidence. To assess the comparative efficacy of routine LSA revascularisation versus either selective or no revascularisation in patients with descending thoracic aortic disease undergoing TEVAR with coverage of the LSA origin. The Cochrane Vascular Trials Search Co-ordinator (TSC) searched the Specialised Register (June 2015). In addition, the TSC searched the Cochrane Register of Studies (CENTRAL (2015, Issue 5)).Trials databases were also searched (June 2015). We had planned to consider all randomised controlled trials (RCTs) that compared routine revascularisation of the LSA with selective or no revascularisation, in patients undergoing TEVAR. Two review authors independently assessed the title and abstract of articles identified through literature searches. An independent third review author was consulted in the event of disagreement. We had planned for two review authors to independently extract data and assess the risk of bias of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. We did not identify any RCTs relevant to our review topic. Therefore, no quantitative analysis was conducted. High quality RCT evidence for or against routine or selective revascularisation of the LSA in TEVAR is not currently available. It is not possible to draw conclusions with regard to the optimal management of LSA coverage in TEVAR, and whether routine revascularisation, which was defined as the intervention of interest in our review, confers beneficial effects, as indicated by reduced mortality, cerebrovascular events, and spinal cord ischaemia. This review highlights the need for continued research to provide RCT evidence and define the role of LSA revascularisation in the context of TEVAR with coverage of the LSA.

Multivariate Analysis of Risk Factors of Cerebral Infarction in 439 Patients Undergoing Thoracic Endovascular Aneurysm Repair.

The aim of the study is to identify the potential risk factors of cerebral infarction associated with thoracic endovascular aneurysm repair (TEVAR).TEVAR was developed as a less invasive surgical alternative to conventional open repair for thoracic aortic aneurysm treatment. However, outcomes following TEVAR of aortic and distal arch aneurysms remain suboptimal. Cerebral infarction is a major concern during the perioperative period.We included 439 patients who underwent TEVAR of aortic aneurysms at a high-volume teaching hospital between July 2006 and June 2013. Univariate and multivariate logistic regression analyses were performed to identify perioperative cerebral infarction risk factors.Four patients (0.9%) died within 30 days of TEVAR; 17 (3.9%) developed cerebral infarction. In univariate analysis, history of ischemic heart disease and cerebral infarction and concomitant cerebrovascular disease were significantly associated with cerebral infarction. “Shaggy aorta” presence, left subclavian artery coverage, carotid artery debranching, and pull-through wire use were identified as independent risk factors of cerebral infarction. In multivariate analysis, history of ischemic heart disease (odds ratio [OR] 6.49, P = 0.046) and cerebral infarction (OR 43.74, P = 0.031), “shaggy aorta” (OR 30.32, P < 0.001), pull-through wire use during surgery (OR 7.196, P = 0.014), and intraoperative blood loss ≥800 mL (OR 24.31, P = 0.017) were found to be independent risk factors of cerebral infarction.This study identified patient- and procedure-related risk factors of cerebral infarction following TEVAR. These results indicate that patient outcomes could be improved through the identification and management of procedure-related risk factors.

Abstract TP354: Trends in Stroke Severity and Incidence After Endovascular Repair for Descending Thoracic Aorta Diseases

Background: Perioperative stroke is a devastating complication after treatment of descending thoracic aorta disease (DTAD). As to whether developments in Thoracic Endovascular repair (TEVAR) influenced the overall stroke burden of patients with DTAD remains to be defined. This study investigated the current incidence and severity of procedure-related stroke in patients undergoing elective or emergency TEVAR. Methods: Patients with DTAD treated by TEVAR were questioned for perioperative stroke. Multivariable logistic regression models with backward variable selection were applied to investigate independent associations with perioperative stroke. Results: Between 2003-2015, 141 consecutive TEVAR (71.6% men;mean age 67.3+16.7years) were performed for DTAD: 58 (41.4%) were emergency procedures. The 30-day mortality was 9.2% (13/141) and 10 patients experienced procedure-related stroke. 30-day mortality was increased in patients with stroke: 23% vs. 5.5% (OR 5.2; 95%CI1.16-23.2;P=0.05). Stroke fatality was even more evident in elective repairs (P=0.049). Procedure-related stroke incidence was higher in emergency (13.3% vs. 2.6%;P=0-02), in procedures with left subclavian artery (LSA) coverage (21.4% vs. 3.5%;P=0.004) and in TEVAR performed before 2007 (15.6% vs 3.1%;P= 0.01). The relationship between increased stroke incidence and LSA coverage (35.7% vs. 6.5%;P=0.01) or procedure before 2007 (26.6% vs.5.1%;P=0.02) was particularly evident in TEVAR performed in emergency, while disappeared in elective repairs. Type of disease and age did not affect stroke risk. In multivariable regression, emergency of repair (OR,10.9; 95%CI,1.56-76.5; P=0.0.2), LSA coverage (OR,10.8; 95%CI 1.8-65.6;P=0.009) and procedure after 2007(OR 0.15; 95%CI 0.03-0.88;P=0.04) were confirmed as independently associated with procedure-related stroke as well as female sex (P=0.034). Conclusions: With developed technology the incidence of procedure-related stroke after TEVAR has declined. This trend was particularly achieved in emergency procedures where the prompt treatment may not allow for accurate planning. Nevertheless, stroke remains a devastating complication at high fatality risk for patients with DTAD even after elective TEVAR.

Zone 2 Thoracic Endovascular Aortic Repair and Left Subclavian Artery Coverage: Revascularization Reduces Stroke Risk

Zone 2 Thoracic Endovascular Aortic Repair and Left Subclavian Artery Coverage: Revascularization Reduces Stroke Risk

Endovascular repair for acute traumatic transection of the descending thoracic aorta: experience of a single centre with a 12-years follow up.

BackgroundMost blunt aortic injuries occur in the proximal proximal descending aorta causing acute transection of this vessel. Generally, surgical repair of the ruptured segment of aorta is associated with high rates of morbidity and mortality and in this view endovascular treatment seems to be a valid and safer alternative. Aim of this article is to review our experience with endovascular approach for the treatment of acute traumatic rupture of descending thoracic aorta.MethodsFrom April 2002 to November 2014, 11 patients (9 males and 2 females) were referred to our Department with a diagnosis of acute transection of thoracic aorta. Following preoperative Computed Tomography (CT) evaluation, thoracic endovascular aortic repair (TEVAR) with left subclavian artery coverage was performed. Follow-up consisted clinical and instrumental (CT, Duplex ultrasound) controls at discharge, 1, 3 and 6 months and yearly thereafter.ResultsAt 12-year follow up, the overall survival for the entire patients cohort was 100 %, no major or minor neurological complications and no episode of left arm claudication occurred. Cardiovascular, respiratory and bleeding complications, in the early period, was represented by minor, non fatal events. No stent graft failure, collapse, leak or distal migration were detected at CT scan during the entire follow up period.ConclusionsAccording to our experience, despite the small number of patient population, TEVAR procedure with with left subclavian artery coverage, performed in emergency settings, seems to provide excellent long term results.Trials registrationThe protocol was registered at a public trials registry, www.clinicaltrials.gov (trial identifier NCT02376998).