Transposition Of Left Subclavian Artery Research Articles

Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble?

Obtaining a suitable proximal landing zone in blunt thoracic aortic injuries (BTAI) often necessitates coverage of the left subclavian artery (LSA). This study aimed to evaluate the outcomes of physician-modified endovascular grafts (PMEGs) in this indication. We performed a retrospective analysis of a prospective registry including all patients who had undergone a thoracic endovascular aortic repair (TEVAR) for BTAI from October 2008 to October 2020. Starting in 2015, patients requiring coverage of the LSA were either treated using a physician-modified proximal scalloped or single-fenestrated stent graft. After an early postoperative computed tomography scan, follow-up was performed at 3 months, 6-months, and yearly. Among 58 patients treated with TEVAR for BTAI, 23 (39.6%) patients required a zone 2 landing zone of which 10 (17.2%) patients were treated with PMEGs. The median age was 48 [31-64.5] years, and 78.2% (n=18) patients were male. The median Injury Severity Score was 38 [27-55.5]. Coverage of the LSA was performed in 25.8% (n=15) of the total population in which 5 patients had an LSA transposition. The median modification time was 18 [14-27] minutes. Technical success of PMEGs was 90.0% overall and 100% for fenestrated stent grafts. No stroke, paraplegia, or retrograde dissection was observed. The primary patency of the LSA in the PMEGs group was 90 % at 1year and 28.8 % in the LSA coverage group (P<0.01). The use of PMEGs is feasible and effective in the management of BTAI with a short proximal landing zone. Further evaluation of long-term outcomes and durability are awaited.

Transposition of left subclavian artery with reimplantation of isolated left vertebral artery before thoracic endovascular aneurysm repair for type B aortic dissection.

Understanding and recognizing anatomic anomalies of the aortic arch is important when planning extra-anatomic debranching before thoracic endovascular aortic repair. A rare anomaly is the left vertebral artery aberrantly arising from the aortic arch; found in ∼5% of adults. When present, the artery courses through the carotid sheath at a variable length before entering the third or fourth cervical transverse foramen. In the present report, we have described the case of a 49-year-old man with a symptomatic, enlarging type B aortic dissection with an aberrant left vertebral artery and the novel methods used to surgically correct his pathology.

Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair

BackgroundLeft subclavian revascularization has become an integral part of thoracic endovascular aortic repair to extend the proximal landing zone. This is most commonly achieved via carotid-subclavian bypass; however, this can be achieved via vessel transposition. MethodsAll patients who had zone 2 thoracic endovascular aortic repairs without branched grafts from 2007 to 2018 were included in the study. The primary outcomes were adverse events, including operative mortality, paraplegia, left arm ischemia, and stroke. Multivariable regression analysis was performed for baseline characteristics associated with adverse events. ResultsA total of 58 patients underwent left subclavian artery transposition for zone 2 thoracic endovascular aortic repair coverage. Operative (30-day) mortality occurred in 3 patients (5.2%). The majority of patients were operated on under urgent (N = 25; 43.1%) or emergency (N = 12; 20.7%) status. Indications for thoracic endovascular aortic repair included aneurysmal disease (34.5%) and type B aortic dissection (chronic [13.8%]; acute [51.7%]). Major adverse events included paraplegia (N = 1; 1.7%), transient paraparesis (N = 3; 5.2%), and stroke (N = 2; 3.4%). Over a mean follow-up of 2.8 years, there were 5 deaths (8.6%). On multivariable analysis, prior stroke (odds ratio, 31.4; 1.95-506.72; P = .02) was an independent predictor of adverse events. ConclusionsCarotid-subclavian transposition offers patients a safe and effective method for left subclavian artery revascularization during thoracic endovascular aortic repair with zone 2 coverage with no increased operative risk and a low complication rate.

Supra-aortic vessel reconstruction in total arch replacement for acute type A dissection: Comparison of en bloc and separate graft techniques

To compare the outcomes of the en bloc and branched graft techniques for supra-aortic vessel reconstruction in total arch replacement (TAR) for acute type A aortic dissection (ATAAD). In 53 ATAAD patients with intact supra-aortic arch vessels undergoing TAR, the arch vessels were reconstructed using the branched graft technique in 35 patients and en bloc technique in 18, i.e. reimplantation of the innominate artery and the left carotid artery (LCA) and transposition of left subclavian artery to LCA. The early and mid-term outcomes were compared between two groups. The selective antegrade cerebral perfusion time in en bloc group was significantly longer (33±10 vs 24±7min, p=0.001). Operative mortality was 5.7% (3/53), including 1 and 2 in the en bloc and branched graft groups, respectively (5.6% vs 5.7%, p=0.981). Stroke occurred in 1 patient. No spinal cord injury occurred. At mean 4.3±1.6 years, clinical and CT follow-up were complete in 100% and 86% (43/50). No cerebrovascular accidents or upper extremity claudication occurred. There were 4 deaths and 1 reintervention in follow-up. Survival was 88.6% and 88.9% at 3 months, and 83.3% and 88.6% at 6 months, 3 and 5 years in the en bloc and branched graft groups, respectively (p=0.597). The arch vessels were patent in 100% (43/43) without stenosis or aneurysm. The modified en bloc technique could achieve comparable early and mid-term outcomes to the branched graft technique in patients undergoing TAR for ATAAD. This approach may be an alternative technique for ATAAD patients with intact supra-aortic arch vessels.

Distal Arch Aneurysm Repair Using Left Subclavian Artery Transposition With Stented Elephant Trunk in the Hybrid Repair Era

Hybrid aortic arch repair is an invasive approach to the surgical management of distal aortic arch aneurysm. The complications associated with hybrid aortic arch repair, such as stroke and endoleaks, are not uncommon and late reintervention is frequent. We retrospectively reviewed our experience of distal aortic arch aneurysm repair using the stented elephant trunk procedure with left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition in the hybrid repair era. Between May 2009 and September 2016, 19 patients with distal aortic arch aneurysm underwent LSCA-LCCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion. All patients were males with a median age of 51±14 (range 20-69) years. There were no in-hospital deaths. Continuous renal replacement therapy was not required in patients with preoperative renal dysfunction after surgery. No neurologic deficits were observed in any patients prior to hospital discharge. One patient underwent concomitant thoracic endovascular aortic repair after this technique. One case required reoperation due to bleeding. One patient required debridement due to poor wound healing. During a mean follow-up of 33±21months, one patient died. Satisfactory results were obtained in suitable patients undergoing surgery for distal aortic arch aneurysm using LSCA-LCCA transposition with stented elephant trunk implantation in the hybrid repair era. The straightforward nature of the surgical approach, with avoidance of the complications related to hybrid aortic arch repair and reduction of late re-intervention favours this technique for treating distal aortic arch aneurysm.

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.

Repair of Complicated Chronic Type B Dissection with Distal Aortic Arch Involvement Using Left Subclavian Artery Transposition with Implantation of a Stented Elephant Trunk.

Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP). Preoperative renal dysfunction was observed in three patients, left heart failure in one patient, and spinal cord ischemia in one patient. Results There was one (5.0%, 1/20) in-hospital death. All but one patient required mechanical ventilation for < 24 hours. Mean duration of mechanical ventilation and mean duration of stay in the intensive care unit was 16 ± 4 and 35 ± 16 hours, respectively. No severe complications occurred. There was one death because of unknown cause during follow-up. One case received thoracoabdominal aortic replacement 9 months after surgery. Conclusion Acceptable surgical outcomes were obtained using LSCA transposition with implantation of a stented elephant trunk. This method is an alternative to TEVAR for complicated chronic type B dissection with involvement of the distal aortic arch.

Proximal scalloped custom-made Relay® stent graft in chronic type B dissection: endovascular repair in a drug abuser patient.

The best solution for enlarging chronic type B aortic dissection is not known. Hybrid surgical and endovascular procedures offer a reliable solution in such circumstances, but technically complex stent-graft designs are sometimes needed when the treatment segment of the aorta presents anatomical challenges. We report a case of a proximally scalloped custom-made stent-graft implantation following left subclavian artery transposition in a formerly cocaine-abuser patient. The one-month follow-up computed tomography angiography showed a proximal endoleak (type Ia) which was successfully solved by coil embolization. Proximally scalloped stent grafts offer a reliable solution in complex aortic dissections involving the supra-aortic branches.

Repair of Distal Aortic Arch Aneurysms by Left Subclavian Artery Transposition with Stented Elephant Trunk Implantation

Repair of distal aortic arch aneurysms remains technically challenging using conventional open surgery due to its location. Several techniques, including a conventional prosthetic graft replacement and a hybrid technique, were introduced to manipulate this lesion. We retrospectively reviewed our experience with left subclavian artery (LSCA) transposition with stented elephant trunk implantation for repair of distal aortic arch aneurysms. From May 2009 to December 2014, 9 men (mean age 55 ± 16 years) with distal aortic arch aneurysms underwent LSCA transposition with stented elephant trunk implantation under hypothermic cardiopulmonary bypass with antegrade selective cerebral perfusion via a median sternotomy. One case had a history of endovascular abdominal aortic repair. There was no in-hospital death. The mean time of mechanical ventilation and intensive care unit stay was 22 ± 9 and 53 ± 17 hr, respectively. No severe complications occurred in this group. All patients survived and were discharged. No patient died during the follow-up period. Postoperative computed tomography revealed good patency of the anastomotic site between the LSCA and the left common carotid artery. Satisfactory surgical results and follow-up outcomes were achieved by simultaneous repair of proximal aortic lesions and complete seal of the lesion involving the distal aortic arch and proximal descending aorta using LSCA transposition with implantation of a stented elephant trunk. Encouraging outcomes favor this technique for distal aortic arch aneurysm.

Stented elephant trunk procedure with left subclavian artery transposition for acute type B dissection with distal arch involvement

ObjectiveComplete or partial supra-aortic debranching, after thoracic endovascular aortic repair, is appealing treatment for complicated acute type B dissection (ABAD) with aortic arch involvement (AAI) because of reduced surgical trauma. However, unsatisfactory outcomes have been reported. We retrospectively reviewed our experience of left subclavian artery (LSCA) transposition with stented elephant trunk (SET) implantation for complicated ABAD with distal AAI. MethodsFrom April 2011 to December 2014, 19 patients (all men; mean age: 44 years) who had complicated ABAD and distal AAI underwent LSCA transposition with SET implantation via a median sternotomy under hypothermic cardiopulmonary bypass with selective cerebral perfusion. Preoperative renal dysfunction was observed in 3 patients, visceral ischemia in 2 patients, and lower-limb ischemia in 1 patient. ResultsNo in-hospital deaths occurred. Seventeen patients required mechanical ventilation for <24 hours, and 2 cases for <48 hours. The mean time of mechanical ventilation and duration of stay in the intensive care unit was 18 ± 6 hours and 44 ± 16 hours, respectively. Ischemia of the viscera and lower limbs after surgery was ameliorated. Continuous renal replacement therapy was not required in 3 patients who had preoperative renal dysfunction. Complete thrombosis of the false lumen at the distal end of the SET was observed in 17 of 18 (94.4%) patients during follow-up. ConclusionsThis method preserves autologous brachiocephalic vessels, excludes the false lumen, promotes thrombosis and remodeling of the distal aorta, and repairs proximal aortic lesions simultaneously. Satisfactory surgical outcomes and follow-up results were achieved using LSCA transposition with SET implantation.

Endovascular treatment of acquired atheromatous aortic arch coarctation.

Acquired aortic coarctation is a rare condition. Its treatment using a percutaneous approach can be challenging, especially when severe calcifications and concomitant aneurysmal disease are present. We report a patient with symptomatic thoracic aorta acquired coarctation and aneurysm that was successfully treated using endovascular technique. After left subclavian artery transposition, a self-expanding endograft was implanted percutaneously, with complete abolishment of the transaortic gradient. Follow-up evaluation at 12 months revealed perfect position of the endograft, persistent reduction of the coarctation, and exclusion of the concomitant aneurysm. A noninvasive pressure reading demonstrated significant systemic blood pressure reduction, with no change in antihypertensive medications.

Repair of Vascular Ring with Resection of Kommerell Diverticulum and Transposition of Aberrant Left Subclavian Artery

A 32-year-old female presented with dysphagia. Radiographic studies revealed external compression of esophagus by a vascular ring. The anatomy was a right-sided aortic arch with aberrant retroesophageal left subclavian artery, emanating from a large Kommerell diverticulum (KD). Traditional repair with ligamentum division and adhesiolysis leaves a large KD still adjacent to the esophagus with the potential for persistent or recurrent symptoms. The objective of this study was the modification of operative technique to minimize the potential for persistent or recurrent symptoms. The operative repair included resection of KD with transposition of the left subclavian artery into the left carotid artery, in addition to the division of the ligamentum arteriosum and mobilization of the esophagus. The patient's dysphagia resolved and postoperative barium studies showed no residual compression. There were no significant perioperative complications. Resection of KD is a potential adjunct to traditional repair of vascular rings and might offer better long-term palliation by minimizing residual vascular compression of the esophagus.

Results and Challenges for the Endovascular Repair of Aortic Arch Aneurysms

Endovascular aortic arch reconstruction provides an attractive alternative to treat aortic arch disease in high-risk patients who would otherwise be unsuitable for open repair. Success with multibranched stent grafts in the thoracoabdominal aorta along with recent advances in design such as the precurved inner nitinol cannula have simplified the endovascular reconstruction of aortic arch aneurysms with multibranched stent grafts. These devices allow for greater flexibility in conforming to difficult anatomy and preserving important side branches. During the first surgical stage, a left carotid -subclavian bypass or left subclavian artery transposition is performed. The second stage is the endovascular procedure. The device is inserted through a transfemoral approach, and crossing of the aortic valve with the device is necessary. The stent graft is deployed during brief periods of rapid pacing. Bridging from the branches to the innominate and left common carotid arteries requires a suitable covered stent. In the case of a large-diameter innominate artery, a custom-made bridging limb has to be used to ensure that adequate length and size are available. Direct flow to the innominate and left common carotid arteries do not cease for any significant time during the procedure. Initial experience with mean follow up more than 6 months is encouraging. The method is not suitable for patients with extensive atheromatous involvement of the aortic arch. Careful preoperative planning (preoperative imaging, device construction, and access issues), high endovascular skills, and appropriate imaging equipment are imperative for a successful result. Long-term follow-up is necessary to evaluate the efficacy and safety of these new devices.

Management strategies for thoracic stent-graft repair of distal aortic arch lesions: is intentional subclavian artery occlusion a safe procedure?

The aim of this retrospective analysis was to assess the clinical consequences after intentional left subclavian artery (LSA) occlusion. Thirty-seven patients, 27 type B dissection and 10 thoracic aneurysm, with short proximal neck (less than 2 cm) underwent endovascular treatment with intentional exclusion of LSA origin. No immediate complications occurred. Mean arterial pressure gradient, between right and left arms, ranged from 15 to 45 mmHg. After a mean follow-up of 43.70 + or - 24.01 months, mild left arm symptoms secondary to flow reduction occurred in eight cases (21.6%) but only one required LSA transposition, after 8 months, for visual impairment. Type II endoleaks from excluded LSA occurred in 10 cases (27.0%): in seven patients, leaks were treated with coils and/or glue embolization; in one case, leak sealed spontaneously; one patient died before leak embolization could occur; one patient refused any further treatment. Intentional exclusion of the LSA may be justified when a longer proximal landing zone in the aortic arch is required.

Thoracic aortic stent grafting: Is it ready for prime time?

16 The Journal of Thoracic and Cardiov Ricco and colleagues 1 are to be congratulated for their comprehensive reporting of the operative results of the French thoracic aortic stent grafting experience over the 2-year period from 1999 through 2001. This is the only report of its kind that depicts the results of an entire country’s experience. It was designed by the French National Health Insurance Fund, with the data verified by third-party advisors. The report is both timely and provocative in the wake of the US Food and Drug Administration’s recent approval of the use of the Gore TAG endograft for thoracic aortic aneurysms in an elective setting. A total of 166 thoracic aortic stent grafts were placed in 29 centers, with no center performing more than 15 cases, and most centers inserting 5 or less grafts in the 2-year period. Although presumably capturing all or most thoracic aortic stent-grafting cases performed in France during the time period, the report is limited in both its scope and its analysis. The most relevant limitations are the report’s retrospective nature and its inherent lack of follow-up data. Despite these flaws, the article reveals several important findings. Devices used included both industrial products (Gore [53%], Medtronic [32%], Stenford [4%], and Boston Scientific [0.5%]) and custom-made grafts designed by the implanting physicians (10%), a profile that is representative of trends around the world. The morbidity and mortality rates by device implanted or by physician specialty (ie, surgeon, radiologist, or cardiologist) are not provided. The overall mortality and major complication rates were significant at 10% and 29%, respectively (although 3 patients were not followed to 30 days). Type I or II endoleaks occurred in 16.3%, but among patients who had proximal descending thoracic aortic coverage (23 patients), 26% had a type I endoleak. Fifteen of the 23 had concomitant left subclavian artery transposition. All type I leaks required additional intervention either by means of open or endovascular techniques. The details of how and when these endoleaks were diagnosed are not provided. Two cases of proximal stent graft migration occurred, but it is not clear whether this migration occurred intraoperatively or postoperatively. None of the type II endoleaks (18 cases) were treated. Follow-up is not provided to demonstrate the natural history or prognosis of these type II leaks in this series. Type III endoleaks were not reported, although 3 of the type I leaks apparently occurred between 2 stent grafts. Paraplegia occurred in 6 (3.6%) patients. Although the anatomic detail and extent of aneurysm coverage is not provided for the patients who had paraplegia, 3 had concomitant abdominal aortic aneurysm repairs. Five of these 6 patients died. Neither spinal drainage nor perioperative evoked potential monitoring was used in any case, a practice that would seem prudent in high-risk cases. Chronic type B aortic dissection was present in 20% of the cases, and the mortality rate among this cohort was 15.2%. There were 17 cases of acute traumatic disruption treated with endografting, with a mortality rate of 6%. There were 3 cases of postoperative aortoesophageal or aortotracheal fistulae, a complication that is less common after conventional open repair. Endografts were placed in 3 patients with known septic aneurysms, and 2 of these patients died within 30 days. Finally, the authors appropriately highlight the fact that at least 17% of the aneurysms treated among the entire group were smaller than 50 mm, and the mortality rate among these cases was 5%. In summary, the report by Ricco and colleagues provides an unbiased glance of what the results of this new technology are likely to be when applied across a wide range of pathology, experience, and expertise. Despite the many advances in the