Left Subclavian Artery Revascularization Research Articles

Left Subclavian Artery Revascularization May Not Influence the Incidence of Spinal Cord Ischemia in Elective Thoracic Endovascular Aortic Aneurysm Repair

To analyze whether left subclavian artery (LSA) revascularization in patients undergoing elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm (TAA) is associated with decreased spinal cord ischemia (SCI). The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with acute aortic dissections or aortic ruptures were excluded from the analysis. Only patients undergoing elective TEVAR for TAA and had their LSA covered during the procedure were included. Patients were divided into two groups according to their LSA revascularization (before or during TEVAR). A descriptive analysis was done to evaluate the change in frequency of LSA revascularization over the study interval. Univariate analysis was done to compare preoperative and intraoperative variables, and primary outcomes of SCI and cerebral stroke between the two groups. Among patients who had elective TEVAR for TAA, 669 patients had the LSA covered. The LSA was revascularized in 67% of these patients (n = 446). The incidence of LSA revascularization increased over the study period (Fig 1) (P < .001). Average age was 69 years, and 65% (n = 433) were male. Demographics and past medical history are summarized in Table I. Spinal cord ischemia developed in 20 patients (3%), and cerebral stroke in 29 patients (4%). No significant difference was seen when comparing postoperative SCI, cerebral stroke, 30-day or 1-year mortality between patients who had LSA revascularization and those who did not (Table II). Long-term survival did not differ between the two groups on Kaplan-Meier analysis (Fig 2). In patients with TAA undergoing elective TEVAR with LSA coverage, an increasing percentage of patients underwent preoperative or concomitant LSA revascularization over the course of the study—81% in 2021. In this study, LSA revascularization, however, did not aff5ct the incidence of postoperative SCI, cerebral stroke, or short or long-term mortality. In conclusion, LSA revascularization did not protect against SCI and may carry its own morbidity in elective TAAs requiring LSA coverage. More detailed studies are needed to help define the role of LSA revascularization in this setting.TableComparison of baseline characteristics, comorbidities, intraoperative variables, and postoperative outcomes between patients who had left subclavian artery (LSA) revascularization and those who did notOverall (n = 669)LSA nonrevascularized (n = 223)LSA revascularized (n = 446)P valueBaseline characteristics Age, years, mean (SD)69 (11)70 (11)69 (11).48 Gender, No. (%).69Male433 (65)142 (64)291 (65)Female236 (35)81 (36)155 (35) Race, No. (%).41African American115 (17)39 (18)76 (17)White474 (71)164 (74)310 (70)Others80 (12)20 (9)60 (14) BMI, mean (SD)28.4 (6.7)28.1 (6.8)28.5 (6.7).45 Smoking status, No. (%).94Never171 (26)59 (27)112 (25)Prior343 (51)113 (51)230 (52)Current154 (23)51 (23)103 (23)Medical History CVD, No. (%)81 (12)31 (14)50 (11).31 CAD, No. (%)111 (17)43 (19)68 (15).19 Congestive heart failure, No. (%)93 (14)33 (15)60 (13).63 COPD, No. (%)193 (29)73 (33)120 (27).12 Hypertension, No. (%)608 (91)199 (89)409 (92).22 Diabetes, No. (%)97 (14)38 (17)59 (13).19 Prior aortic surgery, No. (%)279 (42)103 (46)176 (40).10 Prior aneurysm repair, No. (%)226 (34)82 (36)145 (32).50Intraoperative variables Contrast volume, mL, mean (SD)118 (73)115 (72)120 (73).41 EBL, mL, mean (SD)243 (448)228 (399)251.2 (470).01 Fluoro time, minutes, mean (SD)23.2 (20.3)22.6 (23.0)23.5 (18.9).061 Procedure time, minutes, mean (SD)176 (100)158 (111)186 (94)<.01 Spinal drain placement, No. (%).38None343 (51.4%)111 (49.8%)232 (52.3%)Prophylactic311 (46.6%)106 (47.5%)205 (46.2%)Postoperative11 (1.6%)6 (2.7%)5 (1.1%)Outcomes Spinal cord ischemia, No. (%)20 (3)8 (4)12 (3).52 Cerebral stroke, No. (%)29 (4)9 (4)20 (5).79 30-Day mortality, No. (%)26 (4)5 (2)21 (5).12 1-Year mortality, No. (%)65 (10)21 (9)44 (10).85COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; EBL, estimated blood loss; PCI, percutaneous coronary interventions; SD, standard deviation. Open table in a new tab Fig 2Kaplan-Meier curves comparing long-term survival between patients who underwent left subclavian artery (LSA) revascularization and those who did not.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Left Subclavian Artery Revascularization During Thoracic Endovascular Aneurysm Repair (TEVAR) Is Associated With Improved Long-Term Survival Without Significant Risk For Reintervention

Left subclavian artery revascularization (LSAR) during thoracic endovascular aneurysm repair (TEVAR) is an area of constant debate. Zone 2 aortic pathologies necessitate LSA coverage. Recent studies demonstrated no added immediate benefit for LSAR in chronic type B dissection. We sought to evaluate short and long-term outcomes after LSAR in patients with aneurysmal and nonaneurysmal aortic diseases.

Left Subclavian Artery Coverage is Not Associated with Neurological Deficits in Trauma Patients Undergoing Thoracic Endovascular Repair

Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with an interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population are lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage. The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in 2 groups based on coverage of the LSA. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed. Four hundred and fifty one patients were included in the analysis. There were 268 patients in the LSA not-covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88±0.056 vs. 2.88±0.049 in the covered versus not-covered group (P=0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs. 2.8%, P=0.684 and 0% vs. 2.1%, P=0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups. This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in central nervous system outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data and should be individualized based on each patient's specific clinical scenario.

Spinal cord protection in open and endovascular approaches to thoracoabdominal aortic aneurysms.

Despite advancements in surgical and postoperative management, spinal cord injury has been a persistent complication of both open and endovascular repair of thoracoabdominal and descending thoracic aortic aneurysm. Spinal cord injury can be explained with an ischemia-infarction model which results in local edema of the spinal cord, damaging its structure and leading to reversible or irreversible loss of its function. Perfusion of the spinal cord during aortic procedures can be enhanced by several adjuncts which have been described with a broad variety of evidence in their support. These adjuncts include systemic hypothermia, cerebrospinal fluid drainage, extracorporeal circulation and distal aortic perfusion, segmental arteries reimplantation, left subclavian artery revascularization, and staged aortic repair. The Authors here reviewed and discussed the role of such adjuncts in preventing spinal cord injury from occurring, pinpointing current evidence and outlining future perspectives.

Outcomes of thoracic endovascular aortic repair for penetrating aortic ulcers involving the left subclavian artery with the Castor single-branched stent graft.

To acquire adequate proximal landing zones for penetrating aortic ulcers in the proximal descending aorta or aortic arch, the left subclavian artery (LSA) is usually covered during thoracic endovascular aortic repair. The Castor single-branched stent graft is used to treat aortic disease involving LSA. Our goal was to evaluate the efficiency and safety of the Castor device in treating penetrating aortic ulcers (PAUs) involving the LSA. Between January 2019 and December 2020, we enrolled 25 patients with PAUs requiring LSA revascularization using Castor devices during thoracic endovascular aortic repair (TEVAR). Outcomes including surgical results, 30-day and follow-up deaths and morbidity and aortic computed tomography angiography data were analyzed. In total, 24 patients (96.0%) underwent successful surgical procedures: 1 patient (4.0%) had a type I endoleak and 1 patient (4.0%) had a stroke. Stent migration occurred in 1 patient (4.0%) and paraplegia in 1 patient (4.0%). Two stents were deployed in 2 patients (8.0%). After a mean follow-up period of 15.7 months, 2 cases of branch occlusions and 1 death related to myocardial infarction were noted. Aortic computed tomography angiography demonstrated that the diameters and depths were reduced significantly whereas complete thrombosis of the lumens of the PAUs occurred in all cases during the 12-months follow-up period. These preliminary results justify the efficiency and safety of the Castor single branched stent graft in the treatment of PAUs requiring LSA revascularization.

Long-term patency of surgical left subclavian artery revascularization

ObjectiveLittle is known regarding the long-term patency rates of surgical left subclavian artery (LSA) revascularization, especially when performed concomitant to thoracic endovascular aortic repair and without arterial occlusive disease. Our aim is to contribute to the existing evidence by reporting the patency rates at mid- and long-term follow-up after surgical LSA revascularization. MethodsThis observational, retrospective, single-center cohort study included 90 eligible patients who underwent a left common carotid artery to LSA bypass (72%) or transposition (28%) from December 31, 2017 to January 1, 2000. Data regarding demographics, medical history, intraoperative characteristics, and outcomes regarding bypass graft or transposition patency, severe stenosis, or occlusion were assessed at discharge, 3 months, 1 year, and maximum follow-up using consecutive follow-up computed tomography scans. ResultsIn our predominantly male (74%) cohort with a mean age of 66 years (standard deviation, ±12 years), LSA revascularization was mostly performed concomitant to or adjacent to thoracic endovascular aneurysm repair procedures (98%) with the primary indication for surgery being degenerative or saccular aneurysmatic aortic disease (50%), subacute or acute type B aortic dissection (17%), post-dissection aortic aneurysm (16%), type B intramural hematoma (6%), and other indications (11%). Ninety-seven percent of our left common carotid artery to LSA bypasses were performed using a central, supraclavicular approach, and the other 3% were performed using an infraclavicular approach to the LSA. Median diameter of the bypass was 6 mm (range, 6-12 mm). We found two occlusions at 7.7 and 12.9 months follow-up and four severe stenoses at 21.2, 35.4, 38.3, and 46.7 months follow-up, respectively. Estimated freedom from occlusion was 97% ± 2% and freedom from severe stenosis was 90% ± 4% at both midterm (5 years) and long-term (10 years) follow-up, with a median follow-up duration of 42.2 months for occlusion (25th-75th percentile, 15.4-67.4 months) and 41.9 months (25th-75th percentile, 15.4-67.4 months) for severe stenosis. ConclusionsOpen surgical LSA revascularization may be considered the gold standard to preserve antegrade LSA flow in the context of debranching for thoracic endovascular aneurysm repair or open surgical aortic arch repair, with excellent patency rates at mid-term and long-term follow-up.

A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections.

Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for complicated acute type B aortic dissection (aTBAD). However, the strategy for optimal proximal landing zone remains to be determined. We compared early outcomes and late aortic-related adverse events in patients undergoing TEVAR for complicated aTBAD with endograft deployment in proximal landing zone 2 vs3. We performed a retrospective chart review of adult patients undergoing TEVAR for complicated aTBAD within 6weeks of diagnosis from January 2008 to December 2018. We excluded patients with connective tissue disorders and prior type A repair. Patients were divided into landing zone 2 TEVAR (Z2T) and zone 3 TEVAR (Z3T) groups. Z2 patients were divided between left subclavian artery (LSA) revascularization (Z2R) vs LSA coverage without revascularization (Z2C). Groups were compared for the need for aortic reintervention within 36months of initial admission and freedom from aortic-related adverse events and mortality (AREM), defined as the need for aortic reintervention, aortic-related death, or rupture. Eighty-three patients underwent TEVAR for complicated aTBAD within a mean of 4.1± 7.8days; 89.5% of patients had less than 2cm of healthy proximal descending thoracic aorta. The landing zone was Z3T in 35 patients and 48 underwent Z2T: 10 Z2C and 38 Z2R. There were no differences between Z2T and Z3T in time from diagnosis to TEVAR, demographics, comorbidities, and diameter aortic measurements. The 30-day survival was 87.8%-89.5% for Z2R, 88.6% for Z3, and 80.0% for Z2C (P= .610). The postoperative spinal cord ischemia rate was 3.7%-2.7% for Z2R, 0% for Z3T, and 20.0% for Z2C (P= .012). The postoperative thoracic aortic rupture was 2.2% in Z2 and 0 in Z3. The need for aortic reintervention at 36months after TEVAR was lower for Z2T (10.4%) vs Z3T (31.4%; P= .025). Freedom from AREM at 36months was higher in Z2T vs Z3T (87.5% vs 68.6%; P= .048). The freedom from proximal reintervention was higher in Z2T (95.8%) compared with Z3T (80.0%; P= .019). Z3T deployment was predictive for AREM (odd ratio, 3.648; 95% confidence interval, 1.161-11.465; P= .027) and need for proximal reintervention (odds ratio, 5.542; 95% confidence interval, 1.062-28.927; P= .042). Most patients with aTBAD have less than 2cm of proximal healthy descending thoracic aorta. In patients treated for complicated aTBAD, Z2T is associated with a lower need for aortic reintervention and aortic-related adverse events than Z3T. Patients may benefit from a more aggressive proximal landing zone with similar perioperative morbidity when Z2T is done with LSA revascularization.

Short-term results of chimney stent revascularization of left subclavian artery and Zone 2 thoracic endovascular aortic repair for patients with aortic dissection or transection

Background In this study, we present the short-term results of revascularization of left subclavian artery with the chimney technique in patients with aortic dissection or transection who underwent Zone 2 thoracic endovascular aortic repair. Methods A total of 11 patients (6 males, 5 females; mean age: 56.4±11.5 years; range, 38 to 76 years) who underwent Zone 2 thoracic endovascular aortic repair procedure and left subclavian artery revascularization with the chimney technique between April 2017 and January 2020 in our clinic were retrospectively analyzed. All patients were followed at one, three, six months and one year with computed tomography angiography. Results The mean follow-up was 19.7±14.5 (range, 6.3 to 45.8) months. Endoleak occurred in one (9%) patient and gutter leak occurred in three (27%) patients. The mean endoleak-free (including gutter leak) time was 19.9±5.4 (95% confidence interval: 9.36-30.34) months. No mortality occurred in any of the patients. No occlusion occurred in the chimney grafts. Conclusion The chimney revascularization technique is an alternative to other revascularization techniques of the left subclavian artery during thoracic endovascular aortic repair.

Identifying risk factors for early neurological outcomes following thoracic endovascular aortic repair using the SUMMIT database.

The aim of this study was to assess risk factors for early neurological complications following thoracic endovascular aortic repair (TEVAR) for multiple thoracic aortic diseases using an aggregated dataset. The Study to Assess Outcomes After Endovascular Repair for Multiple Throacic Aortic Disease dataset included data from 6 studies evaluating Zenith thoracic endografts. Post hoc analysis identified early (30-day) neurological complications by TEVAR indication and corresponding risk factors. The study included 594 TEVAR patients (67% male; mean age 66 ± 15 years) with thoracic aortic aneurysm (n = 329), ulcer (n = 56), acute (n = 126) or non-acute (n = 33) type B aortic dissection (TBAD) or blunt injury (n = 50). Overall early stroke rate was 3.5% (n = 21). Overall early paraplegia and paraparesis rates were 1.3% (n = 8) and 2.5% (n = 15), respectively. Multivariable analysis identified acute TBAD [versus others, odds ratio (OR) = 3.47, 95% confidence internal (CI): 1.41-8.52) and longer procedural time (OR = 1.33, CI: 1.02-1.73) as early stroke risk factors. Risk factors for paraplegia or paraparesis included more endografts deployed (OR = 2.43, CI: 1.30-4.55), older age (OR = 1.05, CI: 1.01-1.10) and higher preoperative serum creatinine (OR = 1.31, CI: 1.05-1.64). Endografts landing proximal to the left subclavian artery (LSA) increased stroke rate (versus distal to the LSA; 6.8% vs 2.3%, P = 0.014). Intraoperative LSA revascularization was performed in 20.9% of patients with endografts proximal to the LSA; revascularization did not significantly alter stroke rate (8.1% with revascularization vs 6.4% without, P = 0.72). Acute TBAD and prolonged procedure time increased early stroke risk, while more endografts placed, age and preoperative renal impairment increased early paraplegia or paraparesis risk. For acute TBAD, endograft placement proximal to the LSA, but not LSA patency, increased stroke risk.

Left subclavian artery revascularization in thoracic endovascular aortic repair: single center\u2019s clinical experiences from 171 patients

BackgroundLeft subclavian artery revascularization (LSA) is frequently performed in the setting of thoracic endovascular repair (TEVAR). The purpose of this study was to compare different techniques for LSA revascularization during TEVAR.MethodsWe performed a single center’s retrospective cohort study from 2016 to 2019. Patients were categorized by LSA revascularization methods, including direct coverage without revascularization (Unrevascularized), carotid-subclavian bypass (CSB), fenestrated TEVAR (F-TEVAR). Indications, demographics, operation details, and outcomes were analyzed using standard statistical analysis.Results171 patients underwent TEVAR with LSA coverage, 16.4% (n = 28) were unrevascularized and the remaining patients underwent CSB (n = 100 [58.5%]) or F-TEVAR (n = 43 [25.1%]). Demographics were similar between the unrevascularized and revascularized groups, except for procedure urgent status (p = 0.005). The incidence of postoperative spinal cord ischemia was significantly higher between unrevascularized and revascularized group (10.7% vs. 1.4%; p = 0.032). There was no difference in 30-day and mid-term rates of mortality, stroke, and left upper extremity ischemia. CSB was more likely time-consuming than F-TEVAR [3.25 (2.83–4) vs. 2 (1.67–2.67) hours, p = 0], but there were no statistically significant differences in 30-day or midterm outcomes for CSB versus F-TEVAR. During a mean follow-up time of 24.8 months, estimates survival rates had no difference.ConclusionsLSA revascularization in zone 2 TEVAR is necessary which is associated with a low 30-day rate of spinal cord ischemia. When LSA revascularization is required during TEVAR, CSB and F-TEVAR are all safe and effective methods, and F-TEVAR appears to offer equivalent clinical outcomes as a less time-consuming and minimally invasive alternative.

Anatomic feasibility of off-the-shelf thoracic single side-branched endograft in patients with blunt traumatic thoracic aortic injury

ObjectiveThe advent of thoracic single side-branched endograft (TSSBE) has provided a treatment option to obviate the need for open cervical debranching of the left subclavian artery (LSA), thereby enabling total endovascular incorporation of the LSA during thoracic endovascular aortic repair (TEVAR). In a previous study of patients with type B aortic dissection who had required zone 2 TEVAR, the anatomic feasibility of this device was demonstrated to range from 28% to 35%, suggesting limited applicability of the currently available designs. The objectives of the present study were twofold: (1) to evaluate the anatomic feasibility of TSSBE in blunt traumatic thoracic aortic injury (BTAI) patients who would require LSA revascularization; and (2) to describe the anatomic characteristics of the supra-aortic arch branches that could be used to improve future device design. MethodsA retrospective review was performed of BTAI patients who had undergone TEVAR at a single institution from November 2013 to October 2018. Preoperative computed tomography angiograms were analyzed using three-dimensional reconstruction to quantify the aortic diameter, distance and arc length between branch vessels, and the LSA diameter and length. We calculated the proportion of patients who had met all aortic and LSA anatomic requirements for TSSBE proposed by investigational protocols. We also assessed the effect of anatomic requirement modifications on device suitability. Finally, we assessed the local anatomic relationship between the supra-aortic branches. ResultsA total of 41 patients (63% men; median age, 39 years; range, 23-88 years; 68% normal aortic arch pattern, 32% bovine aortic arch pattern) with BTAI who had required TEVAR involving the LSA and were, thus, considered potential candidates for TSSBE were included. Of the 41 patients, 13 (32%; 7 with a bovine aortic arch and 6 with a normal aortic arch) had met all proposed aortic and LSA anatomic requirements for TSSBE. An appropriate aortic diameter, LSA diameter, and LSA length to its first branch were observed in 100%, 95%, and 66% of the patients, respectively. An insufficient distance between the arch branch vessels, observed in 41%, was the most common exclusionary criterion. The median clock-face position of the LSA was 12:00 (interquartile range, 30 minutes) in the normal arch group and 11:45 (interquartile range, 15 minutes) in the bovine arch group. ConclusionsDespite the numerous potential advantages of TSSBE, only 32% of patients with BTAI requiring LSA revascularization had met all the aortic and LSA anatomic requirements, justifying the need for additional designs. Better characterization and mapping of the aortic arch branches will improve future device design and application.

In Situ Laser Fenestration for Delayed Left Subclavian Artery Revascularization Following Thoracic Endovascular Aortic Repair of Type B Aortic Dissection.

In situ laser fenestration (ISLF) is currently used to reconstruct the aortic major branches during thoracic endovascular aortic repair (TEVAR). To our knowledge, there have been no reports on the application of ISLF for delayed revascularization of the LSA previously sealed in TEVAR. This report describes 5 patients who underwent ISLF for delayed LSA revascularization, with a technical success rate of 80%. No endoleakage occurred, and stents remained patent during more than 6-month follow-up. ISLF is an effective, safe and minimally invasive method for delayed revascularization of the LSA following TEVAR for type B aortic dissection (TBAD) when patients are selected appropriately.

Endovascular Repair for Acute Type B Aortic Dissection With Unfavorable Proximal Landing Zone

BackgroundThe study aimed to compare the safety and effectiveness between fenestrated technique with or without chimney stent and single-branched stent graft for isolated left subclavian artery revascularization during endovascular repair of acute type B aortic dissection with unfavorable proximal landing zone. MethodsFrom January 2016 to December 2019, 65 acute type B aortic dissection patients with unfavorable proximal landing zone were treated with either the fenestrated technique (n = 34, group A) or single-branched stent graft (n = 31, group B). Type I endoleak, retrograde type A dissection, stroke, left subclavian artery patency, 30-day mortality, and aortic remodeling were systematically recorded and retrospectively analyzed. ResultsTechnical success rates for groups A and group B were 94.12% and 100%, respectively. Left subclavian artery primary patency was achieved for all enrolled patients. The incidence of type I endoleak, retrograde type A dissection, stroke, and 30-day mortality was 5.9%, 5.9%, 2.9%, and 2.9% in group A, respectively, but none were encountered in group B. Left subclavian artery occlusion was observed in 3 patients in group A and 2 patients in group B during a mean follow-up of 16.18 ± 2.08 months and 15.19 ± 2.68 months, respectively. After the procedure, significant aortic remodeling was detected in both groups during follow-up. ConclusionsBoth techniques are feasible and safe for isolated left subclavian artery revascularization during endovascular repair for acute type B aortic dissection. Apart from the associated perioperative risks of complications and mortality for the fenestrated technique, both procedures contributed to favorable aortic remodeling.

Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke.

The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010-1 August 2020. Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.

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.

Treatment strategies of spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysm

It is more than 20 years since the first endovascular repair of thoracoabdominal aortic aneurysm was performed. Significantly reducing risk of morbidity and mortality compared with open aortic repair, the advent of endovascular repair has revolutionized the treatment of complex aortic disease. It is now the first-line treatment for most thoracoabdominal aortic aneurysm patients. However, spinal cord ischemia (SCI) remains one of the most threatening complications after the procedure, and significantly reduces overall survival. The pathophysiology of spinal cord ischemia remains unclear but may well be multifactorial. Risk factors for SCI include excessive aortic coverage, detriment to the collateral network through occlusion of the left subclavian or internal iliac arteries, perioperative hypotension and chronic renal failure. SCI could be predicted, prevented and ameliorated through the application of motor evoked potential, permissive perioperative hypertension, cerebrospinal fluid drainage (CSFD), preoperative or concomitant left subclavian artery (LSA) revascularization and some drugs. However, there are certain complications and contraindications for CSFD and arterial revascularization. As a result, we must balance the pros and cons of these invasive measures. So we summarize our clinical experience and propose the employment of LSA revascularization and CSFD in certain kinds of high-risk patients respectively. With the development of technology and preventive measures, we believe that SCI could be minimized in the forseeable future.

Anatomic Feasibility of Off-the-Shelf Thoracic Single Side-Branched Endograft in Patients With Blunt Traumatic Thoracic Aortic Injury

The advent of thoracic single side-branched endograft (TSSBE) has provided a treatment option to obviate the need for open cervical debranching of the left subclavian artery (LSA), thereby enabling total endovascular incorporation of the LSA during thoracic endovascular aortic repair (TEVAR). In a previous study of patients with type B aortic dissection who had required zone 2 TEVAR, the anatomic feasibility of this device was demonstrated to range from 28% to 35%, suggesting limited applicability of the currently available designs. The objectives of the present study were twofold: (1) to evaluate the anatomic feasibility of TSSBE in blunt traumatic thoracic aortic injury (BTAI) patients who would require LSA revascularization; and (2) to describe the anatomic characteristics of the supra-aortic arch branches that could be used to improve future device design. A retrospective review was performed of BTAI patients who had undergone TEVAR at a single institution from November 2013 to October 2018. Preoperative computed tomography angiograms were analyzed using three-dimensional reconstruction to quantify the aortic diameter, distance and arc length between branch vessels, and the LSA diameter and length. We calculated the proportion of patients who had metall aortic and LSA anatomic requirements for TSSBE proposed by investigational protocols. We also assessed the effect of anatomic requirement modifications on device suitability. Finally, we assessed the local anatomic relationship between the supra-aortic branches. A total of 41 patients (63% men; median age, 39years; range, 23-88years; 68% normal aortic arch pattern, 32% bovine aortic arch pattern) with BTAI who had required TEVAR involving the LSA and were, thus, considered potential candidates for TSSBE were included. Of the 41 patients, 13 (32%; 7 with a bovine aortic arch and 6 with a normal aortic arch) had metall proposed aortic and LSA anatomic requirements for TSSBE. An appropriate aortic diameter, LSA diameter, and LSA length to its first branch were observed in 100%, 95%, and 66% of the patients, respectively. An insufficient distance between the arch branch vessels, observed in 41%, was the most common exclusionary criterion. The median clock-face position of the LSA was 12:00 (interquartile range, 30minutes) in the normal arch group and 11:45 (interquartile range, 15minutes) in the bovine arch group. Despite the numerous potential advantages of TSSBE, only 32% of patients with BTAI requiring LSA revascularization had metall the aortic and LSA anatomic requirements, justifying the need for additional designs. Better characterization and mapping of the aortic arch branches will improve future device design and application.

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.

Periscope sandwich stenting as an alternative to open cervical revascularization of left subclavian artery during zone 2 thoracic endovascular aortic repair

ObjectiveRevascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications, including stroke, spinal cord ischemia, and upper extremity ischemia. Both open surgical and endovascular LSA revascularization techniques have been described, each with unique risks and benefits. We describe our “periscope sandwich” technique for the LSA during zone 2 TEVAR, which maintains antegrade access to the distal abdominal aorta if subsequent interventions are necessary. Technical results and short-term outcomes are compared with LSA open surgical debranching. MethodsA single-institution retrospective review was performed for patients requiring zone 2 TEVAR with LSA revascularization by periscope sandwich technique or open surgical debranching with subclavian to carotid transposition (SCT) or carotid-subclavian bypass (CSB). The presenting aortic disease and perioperative details were recorded. Intraoperative angiography and postoperative computed tomography images were reviewed for occurrence of endoleak and branch patency. ResultsBetween January 2013 and December 2018, the LSA was revascularized by periscope sandwich in 18 patients, SCT in 22 patients, and CSB in 13 patients. Compared with open surgical debranching, periscope sandwich had a lower median estimated blood loss (100 mL vs 200 mL for pooled SCT and CSB; P = .03) and lower median case duration (133.5 minutes vs 226 minutes; P < .001). Contrast material volume (120 mL vs 120 mL; P = .98) and fluoroscopy time (13.1 minutes vs 13.3 minutes; P = .92) did not differ significantly between the groups. There was no difference in aorta-related mortality (P = .14), and LSA patency was 100%. Median follow-up for the periscope sandwich group was 11 months, with an overall estimated 91% freedom from gutter leak at 6 months. ConclusionsLSA periscope sandwich technique provides safe and effective LSA revascularization during zone 2 TEVAR. LSA periscope sandwich can be used emergently with off-the-shelf endovascular components and facilitates future branched-fenestrated endovascular repair of thoracoabdominal aortic diseases.