Left Subclavian Artery Coverage Research Articles

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

BackgroundWe performed routine spinal fluid drainage for patients who underwent TEVAR for thoracic aortic pathology together with left subclavian artery coverage, which was needed for achievement of a safe proximal sealing zone. We assessed the occurrence of spinal cord ischemia as well the rate of occurrence of other complications such as stroke, and upper limb ischemia.ResultsThis was a case series study done between July 2014 and April 2020, in them all the left subclavian artery was covered to ensure a proximal safe seal zone. Routine spinal fluid drainage was done, keeping the spinal fluid pressure < 10–15 mmHg with catheter in place for 48 h. Data was obtained from twenty-three patients who underwent TEVAR for thoracic aortic dissection (73.91%), thoracic aortic aneurysm (21.74%), or ulcer (4.35%). Planning was based upon multi-slice computed tomographic angiography and covering the left subclavian was mandatory to achieve a proximal sealing zone. Technical success was achieved in 100% of cases. 4.35% of patients had three endograft, 56.52% had two endografts, 39.13% had one endograft. All patients lost their radial pulsations immediately after implantation, 8.70% developed post implantation syndrome(fever) that was managed conservatively, 4.35% developed stroke related to the anterior circulation, 4.35% developed signs of spinal cord ischemia. During the follow up, one patient died within 6 h after the procedure due to extensive myocardial infarction (patient was scheduled for CABG after our procedure). 17.40% developed upper limb symptoms that were tolerable and were managed conservatively.ConclusionBy adopting routine spinal cord drainage and pressure monitoring, we can consider not to revascularize the left subclavian artery prior to TEVAR if it will be covered.

Long-term results of left subclavian artery coverage during thoracic endovascular aortic repair: A single center study

Long-term results of left subclavian artery coverage during thoracic endovascular aortic repair: A single center study

Five-year Outcomes With Conformable GORE TAG Endoprosthesis Used in Traumatic Aortic Transections

BackgroundThe Conformable GORE TAG thoracic endoprosthesis (CTAG) device (W.L. Gore and Associates, Flagstaff, AZ) seeks to optimize thoracic endovascular repair of blunt aortic injuries by better apposition to the aortic arch. The Evaluation of the GORE Conformable TAG Thoracic Endoprosthesis for Treatment of Traumatic Transection (TAG 08-02) study assessed the safety and effectiveness of the CTAG device in the 5 years after treatment. MethodsThis prospective, single-arm study was conducted at 30 US sites with follow-up through 5 years. Patients were evaluated for all-cause mortality and device events through follow-up. An independent core laboratory reviewed pretreatment and posttreatment images. ResultsA total of 51 initial cohort patients and 50 continued access patients were enrolled and underwent placement of a total of 111 CTAG devices (mean, 1.1/subject; range, 1.0 to 3.0) during initial treatment. On average, patients were 42.7 ± 19.5 years old, with a mean Injury Severity Score of 31.5 ± 14.5, and most presented with polytraumatic injuries. The median time between injury and treatment was 21.0 hours (range, 3.2 to 334.4 hours). A total of 60 patients had partial or complete left subclavian artery coverage, but only 1 patient had a stroke that was unable to be attributed to the device or procedure. The freedom from all-cause mortality was 95% and 89% at 1 month and 5 years after the procedure, respectively. There were 2 minor endoleaks. No aortic ruptures, wire frame fractures, erosions, lumen obstructions, device compressions, or thrombus-related events were reported. ConclusionsThe 5-year outcomes verify that the CTAG device is a safe, effective, and durable option for patients with blunt aortic injuries who are undergoing thoracic endovascular aortic repair.

Surgeon-modified fenestrated stent graft deployment in type B aortic dissection.

The treatment of aortic dissections and aneurysms may be challenging for vascular surgeons. Currently, thoracic endovascular aortic repair is usually the first treatment option for descending aortic pathologies. Left subclavian artery coverage during this procedure is often required to achieve a sufficient proximal landing zone. Most surgeons agree that the left subclavian artery can be selectively covered, but revascularization is preferred to reduce the risk of neurological or ischemic complications. The chimney method, hybrid operations with extra-anatomic bypass, back table or in situ fenestrations are assistive techniques in this procedure. Herein, we present a surgeon-modified fenestrated stent graft for a type B aortic dissection patient.

Complex endovascular repair of type B aortic dissection and predicting left arm ischemia: a case report

BackgroundThoracic endovascular aortic repair (TEVAR) is the gold standard for surgical management of descending thoracic aortic pathology. Depending on the anatomy, TEVAR often requires deployment across the origin of the left subclavian artery (LSA) to obtain a proximal seal, thus potentially compromising perfusion to the left upper extremity (LUE). However, in most patients this is generally well tolerated without revascularization due to collateralization from the left vertebral artery (LVA).Case presentationWe present a complex 59-year-old Caucasian patient case of TEVAR with a history of prior arch debranching and intraoperative LSA coverage requiring subsequent LSA embolization and emergency take-back for left carotid–subclavian bypass.ConclusionThe purpose of this case report is to highlight an often overlooked anatomic LVA variant and an atypical, delayed presentation of acute LUE limb ischemia.

Partial subclavian artery coverage in TEVAR patients for acute type B aortic dissections: an alternative solution.

Acute type B aortic dissection with origin of the left subclavian artery (LSA) is generally managed with endovascular therapy for acute coverage of the LSA with: 1) no revascularization; 2) revascularization with open methods; or 3) endovascular revascularization. To identify an alternative solution, we critically evaluated a small cohort of patients who had partial coverage of their LSA. Three thoracic endovascular repairs were performed from January-March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative management. Indications included acute type B dissection with lower extremity ischemia, ruptured dissection, and persistent symptoms of dissection after medical therapy. Technical success was achieved in all three patients, and all procedures were performed percutaneously. The mean distance between the ostium of the LSA and the entry point of dissection was 11.1±3.4 mm. Within the 30-day postoperative period, there were no deaths, aortic ruptures, myocardial infarctions, or conversions to open repair. Freedom from re-intervention was noted in all 3 patients. There was no spinal cord ischemia. There is no strong evidence to support the current optimal approach for treatment of the thoracic aorta. Partial coverage of LSA in patients with <2 cm seal zones may be considered as an alternative. However, due to our small sample size, limited follow-up, and lack of comparison cohort, further investigation is necessary.

Reevaluating the Need for Routine Coverage of the Left Subclavian Artery in Thoracic Blunt Aortic Injury

Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for thoracic blunt aortic injury (TBAI). A 20mm proximal seal zone is recommended based on aneurysmal disease literature which often results in coverage of the left subclavian artery (LSA). The aim of this study was to analyze our experience with TEVAR for TBAI and evaluate whether 20mm is required to achieve successful remodeling. This is a single-center, retrospective study of all consecutive patients who received a TEVAR for treatment of moderate and severe TBAI between April 2014 and November 2018. Three-dimensional software reconstruction was used for computed tomography (CT) scan centerline measurements. Outcomes included technical success, need for reinterventions, and immediate and long-term aortic-related complications. Sixty-one patients underwent TEVAR for TBAI during the study period. Twenty-eight (46%) patients underwent LSA coverage with an average distance from the LSA to the injury of 6.4mm (0-15.1mm). Of the 33 (54%) patients who did not undergo coverage of the LSA, 22 patients (66%) had less than 20mm of proximal seal zone. The mean distance from the LSA to injury in this group was 16.6mm (7.9-29.5mm). None of the patients with LSA coverage developed ischemic symptoms, and an average decrease in left arm systolic blood pressure of 24.8mm Hg (0-62mm Hg) was noted versus the right arm. There was no aortic-related mortality in either group. Follow-up CT scans revealed excellent remodeling. Immediate outcomes of TEVAR for TBAI with LSA coverage are well tolerated; however, the long-term sequela of LSA coverage is unknown. Exclusion of the injury and excellent remodeling appear to occur with less than 20mm of proximal seal, and perhaps more attention should be made to preservation of the LSA.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR

Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

Early Outcomes of Left Subclavian Artery Revascularization Using Castor Single-Branched Stent-Graft in the Treatment of Type B Aortic Dissection or Intramural Hematoma.

Background: More evidence was required to guide the management of left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR). The present study aimed to compare the outcomes of LSA coverage with LSA revascularization. Another purpose of this study was to share our experience of LSA revascularization with castor single-branched stent-graft.Methods: From January 2016 to December 2019, 134 patients with type B aortic dissection (TBAD) or intramural hematoma (IMH) were enrolled and divided into two groups, the LSA-covered group (n = 61) and the LSA-revascularized group (with castor single-branched stent-graft, n = 73). The results, such as in-hospital and 30-day mortality, stroke, paraplegia, left arm ischemia, operation time, endoleak, were compared between the two groups.Results: The incidence of 30-day stroke in the LSA-covered group (8.2%) was significantly higher compared with the LSA-revascularized group (0%, P = 0.018). 30-day ischemia of left arm occurred in more patients in the LSA-covered group (11.5%, P = 0.003). No statistical difference was found in the incidences of paraplegia, endoleak, in-hospital mortality, and 30-day mortality.Conclusions: LSA should be revascularized during TEVAR to reduce the incidences of stroke and left arm ischemia. Castor single-branched stent-graft was feasible and safe for treating TBAD or IMH.

Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience

Objective In blunt trauma patients, injury of the thoracic aorta is the second most common cause of death after head injury. In recent years, thoracic endovascular aortic repair (TEVAR) has largely replaced open repair as the primary treatment modality, and delayed repair of stable aortic injuries has been shown to improve mortality. In light of these major advancements, we present a 10-year institutional experience from a tertiary cardiovascular surgery center. Methods Records of patients who underwent endovascular or open repair of the ascending, arch or descending thoracic aorta between January 2009 and December 2018 were retrospectively analyzed. Patients without blunt traumatic etiology were excluded. Perioperative data were retrospectively collected from patient charts. Long-term follow-up was performed via data from follow-up visits and phone calls. Results A total of 1,667 patients underwent 1,740 thoracic aortic procedures (172 TEVAR and 1,568 open repair). There were 13 patients (12 males) with a diagnosis of blunt thoracic aortic injury. Mean patient age was 43.6 years (range, 16–80 years). Ten (77%) patients underwent TEVAR, two (15.4%) underwent open repair, and one (7.7%) was treated nonoperatively. Procedure-related stroke was observed in one (7.7%) case. Procedure-related paraplegia did not occur in any patients. Left subclavian artery origin was covered in seven patients. None developed arm ischemia. Hospital survivors were followed-up for an average of 60.2 months (range, 4–115 months) without any late mortality, endoleak, stent migration, arm ischemia, or reintervention. Conclusion Blunt thoracic aortic injury is a rare but highly fatal condition. TEVAR offers good early and midterm results. Left subclavian artery coverage can be performed without major complications.

Low-density vulnerable thrombus/plaque volume on preoperative computed tomography predicts for spinal cord ischemia after endovascular repair for thoracic aortic aneurysm

BackgroundSimilar to open surgical repair, thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI). However, the generally lower incidence of SCI after TEVAR compared with that after open surgical repair, despite the inability to preserve the intercostal arteries, indicates different pathophysiologic mechanisms with the two procedures. We hypothesized that a microembolism from an aortic mural thrombus is the main cause of SCI. Thus, we evaluated the association between the density of a mural thrombus in the descending thoracic aorta and the development of SCI. MethodsA retrospective review of a prospectively assembled database was performed for all patients who had undergone surgery at a single institution from October 2008 to December 2018. Patient demographics and procedure-related variables were collected. The volume and Hounsfield unit (HU) value of mural thrombi in the whole descending thoracic aorta were estimated on preoperative computed tomography using a three-dimensional workstation. Logistic regression analysis was performed to identify the risk factors for SCI development. ResultsOf the 367 patients who had undergone TEVAR during the study period, 155 were excluded because of previous arch surgery (n = 59), previous descending thoracic aortic surgery (n = 6), previous TEVAR (n = 6), unavailability of optimal preoperative computed tomography data (n = 17), double-barreled dissection (n = 40), and other reasons. The mean ± standard deviation age of the remaining 212 patients was 75.8 ± 6.4 years, and 42 (19.8%) were women. Of the 212 patients, 14 (6.6%) developed SCI after TEVAR. The low mean density of the mural thrombus, total thrombus volume, low-density (≥−100 HU but <30 HU) thrombus volume, intermediate-density (≥30 HU but <150 HU) thrombus volume, treatment length, urgent surgery, and baseline dialysis differed significantly between patients with and without SCI. Although subsequent multivariate analysis could not be performed owing to the small number of SCI events, vulnerable low-density thrombus/plaque was a stronger predictor among the aneurysm-related factors of SCI after TEVAR on univariate analysis. Well-known risk factors, such as distal coverage between T8 and L1, left subclavian artery coverage, previous abdominal aortic surgery, and prophylactic spinal drainage, did not show significant differences. ConclusionsThe results from the present study have demonstrated that among aneurysm-related factors, a lower density mural thrombus/plaque in the descending thoracic aorta is a predictor of SCI development after TEVAR. These results suggest that microembolism is one of the important mechanisms of SCI after TEVAR, which might change the prophylactic strategy.

Left Subclavian Artery Coverage during Endovascular Repair of Blunt Thoracic Aortic Injuries: Extending the Proximal Seal Zone May Increase the Risk of Stroke

Buchanan, Frank R. MBA; Leede, Emily BA; Cardenas, Tatiana C.P. MD; Aydelotte, Jayson MD, FACS; Trust, Marc D. MD; Ali, Sadia MPH; VR Brown, Carlos MD, FACS; Teixeira, Pedro G. MD, FACS; DuBose, Joseph J. MD, FACS Author Information

Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With High 30-Day Stroke Incidence With or Without Concomitant Revascularization

Review of the National Surgical Quality Improvement Program registry from 2005 to 2017 The stroke incidence was 2% after elective thoracic endovascular aortic repair (TEVAR) without left subclavian artery (LSA) coverage compared with 5% with LSA coverage (P < .001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized vs 4.4% without concomitant revascularization. LSA coverage was significantly associated with stroke both with and without concomitant revascularization. Stroke after TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.

Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection.

Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident (P = .16), spinal cord ischemia (P = 1.00), or death (P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

Blunt thoracic aortic injury and TEVAR: long-term outcomes and health-related quality of life

PurposeTreatment of blunt thoracic aortic injuries (BTAIs) has shifted from the open surgical approach to the use of thoracic endovascular aortic repair (TEVAR), of which early outcomes appear promising but controversy regarding long-term outcomes remains. The goal of this study was to determine the long-term TEVAR outcomes for BTAI, particularly radiographic outcomes, complications and health-related quality of life (HRQoL).MethodsRetrospectively, all patients with BTAIs presented at a single level 1 trauma center between January 2008 and December 2018 were included. Radiographic and clinical outcomes were determined (early and long term). In addition, HRQoL scores using EuroQOL-5-Dimensions-3-Level (EQ-5D-3L) and Visual Analog Scale (EQ-VAS) questionnaires were assessed, and compared to an age-adjusted reference and trauma population.ResultsThirty-one BTAI patients met the inclusion criteria. Of these, 19/31 received TEVAR of which three died in hospital due to aorta-unrelated causes. In total, 10/31 patients died due to severe (associated) injuries before TEVAR could be attempted. The remaining 2/31 had BTAIs that did not require TEVAR. Stent graft implantation was successful in all 19 patients (100%). At a median radiographic follow-up of 3 years, no stent graft-related problems (endoleaks/fractures) were observed. However, one patient experienced acute stent graft occlusion approximately 2 years after TEVAR, successfully treated with open repair. Twelve patients required complete stent graft coverage of the left subclavian artery (LSCA) (63%), which did not result in ischemic complaints or re-interventions. Of fourteen surviving TEVAR patients, ten were available for questionnaire follow-up (follow-up rate 71%). At a median follow-up of 5.7 years, significant HRQoL impairment was found (p < 0.01).ConclusionThis study shows good long(er)-term radiographic outcomes of TEVAR for BTAIs. LSCA coverage did not result in complications. Patients experienced HRQoL impairment and were unable to return to an age-adjusted level of daily-life functioning, presumably due to concomitant orthopedic and neurological injuries.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During Thoracic Endovascular Aortic Repairs

Thoracic endovascular aortic repairs (TEVAR) have become the procedure of choice for aneurysms of the descending thoracic aorta and type B aortic dissection since their approval by the US Food and Drug Administration in 2005. Coverage of the left subclavian artery (LSA) is commonly required when TEVAR is performed in zone 3 of the descending thoracic aorta to allow for an adequate proximal landing zone for the endograft. Practice guidelines from the Society for Vascular Surgery suggest routine revascularization following LSA coverage in several categories of patients.

Thirty-Day Readmissions After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection

Management of type B aortic dissection (TBAD) with thoracic endovascular aortic repair (TEVAR) carries a significant resource burden for the admitting hospital, including costs related to 30-day readmissions. Our objective was to define the patient population for 30-day readmissions after TEVAR for aortic dissection and to identify risk factors, readmission reasons, and possible preventive measures to reduce this readmission rate. A retrospective review of a prospectively collected database of all TEVARs performed to treat TBAD at a quaternary-level institution was performed. Patients readmitted to any of the institution's nine acute care hospitals within 30 days were identified and analyzed to characterize the significant demographic, comorbid, operative, and medical factors associated with readmission. Between 2012 and 2019, 294 patients underwent TEVAR for treatment of acute (n = 95 [48.8%]), subacute (n = 37 [12.6%]), or chronic (n = 112 [38.2%]) TBAD. Of the 279 patients alive at discharge, 45 patients (16.1%) were readmitted within 30 days, with a mean time to readmission of 11.8 ± 8.9 days. Readmission primary diagnosis was most commonly aorta related (n = 13 [28.9%]) or heart related (n = 11 [24.4%]); other reasons included gastroenterologic (n = 6 [13.3%]), neurologic (n = 5 [11.1%]), pulmonary related (n = 4 [8.9%]), infectious (n = 3 [6.7%]), and nonclassified (n = 2 [4.4%]). Of 45 readmitted patients, 7 (15.5%) underwent a secondary intervention during the index readmission. Preoperative renal failure (creatinine concentration >1.5 mg/dL) was associated with an increased rate of 30-day readmission (31.1% vs 16.7%; P = .024), as was private insurance status (26.7% vs 13.7%; P = .029). Patients who underwent intentional left subclavian artery coverage (zone 2) or had visceral/renal stents implanted at the time of TEVAR trended toward higher 30-day readmission rates compared with patients undergoing descending thoracic aortic coverage (zone 3-5) only (46.7% vs 37.8% vs 15.6%; P = .088). Blood pressure range and heart rate range in the 24-hour period before discharge were not predictive of 30-day readmission. Pain status and creatinine level at discharge were also not associated with increased rate of 30-day readmission. A consequential number of patients require readmission within 30 days after surgical treatment of TBAD with TEVAR. Reasons for readmission are commonly aorta related and heart related and are associated with preoperative renal failure and insurance status. Increased case complexity, including coverage of the left subclavian artery or the need for visceral/renal stenting at the time of TEVAR, is an independent predictor of increased 30-day readmission rate. Effectiveness of medical impulse control was not associated with 30-day readmission. These data provide insight into the quality-oriented metrics associated with endovascular treatment of TBAD.

Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With a High 30-Day Stroke Incidence With or Without Concomitant Revascularization

Purpose: To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. Materials and Methods: The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). Results: The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Conclusion: Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.

Applicability of a standardized thoracic endograft with a single branch for the left subclavian artery to treat aortic disease involving the distal arch

ObjectiveCoverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device. MethodsThe preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration. ResultsThere were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was −10 minutes (−30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA <20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition. ConclusionsThe low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft.

Five-Year Outcomes From the United States Pivotal Trial of Valiant Captivia Stent Graft for Blunt Aortic Injury

The Clinical PeRformancE of the Valiant Thoracic Stent Graft with Capitvia Delivery System for the EndovaSCUlar treatment of Blunt Thoracic Aortic Injuries (RESCUE) study evaluating thoracic endovascular repair using the Valiant Captivia endograft for blunt thoracic aortic injury reported promising 30-day outcomes. We now describe 5 years of follow-up of this cohort. Fifty patients (mean age 40.7 ± 17.4 years, 76% male, mean injury severity score 38 ± 14.4) were treated for blunt thoracic aortic injury (2010 to 2012) with this endograft. Seventy percent (n= 35) of blunt thoracic aortic injury extent was grade III or higher. Extent of arch repair required full (40%) or partial (18%) left subclavian artery coverage. At 5 years, clinical and imaging compliance was 90.3% (28 of 31) and 67.7% (21 of 31), respectively. Thirty-day mortality was 8%. Three additional patients died of non-device-related causes (respiratory failure, infection, metastatic cancer) through 5-year follow-up, yielding a Kaplan-Meier survival of 85.2% through 5 years. Neither stroke nor spinal cord ischemia was observed at 5 years. Two type II endoleaks seen at 30 days resolved spontaneously, and no additional endoleaks were described in the study cohort through 5 years. No secondary endovascular procedures or conversion to open surgery were reported through 5 years. Four subjects underwent left subclavian revascularization for symptomatic indications. Finally, complete exclusion of the traumatic injury was maintained with no incidences of stent graft kinking, fracture, loss of patency, or migration through 5 years in all patients. This multicenter clinical trial describes excellent 5-year outcomes and durable exclusion of blunt thoracic aortic injury using a novel stent graft system. Thoracic endovascular repair with this endograft appears to be a safe and effective treatment option for patients with blunt thoracic aortic injury.