How to manage the left subclavian artery during endovascular stenting of the thoracic aorta☆

Abstract 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.

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Can the Left Subclavian Artery be Safely Covered during Endovascular Repair of the Descending Thoracic Aorta?

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31817793f8 ◽

2008 ◽

Vol 3 (3) ◽

pp. 147-150 ◽

Cited By ~ 4

Author(s):

Ourania Preventza ◽

Grayson H. Wheatley ◽

James Williams ◽

Hannan Chaugle ◽

Kakra Hughes ◽

...

Keyword(s):

Thoracic Aorta ◽

Subclavian Artery ◽

Endovascular Repair ◽

Left Subclavian Artery ◽

Left Internal Mammary Artery ◽

Artery Bypass ◽

Bypass Graft ◽

Descending Thoracic Aorta ◽

Complete Coverage ◽

Internal Mammary

Objective Routine preoperative carotid-subclavian bypass or transposition is frequently recommended in patients undergoing endovascular repair of the descending thoracic aorta (DTA). We reviewed our comprehensive thoracic endografting experience with regards to coverage of the left subclavian artery (LSA) to assess whether mandatory preoperative carotid-subclavian bypass or transposition is necessary. Methods Between February 2000 and November 2005, 255 patients were successfully treated with an endoluminal graft (ELG) to the DTA. Indications for intervention included atherosclerotic aneurysms (109/255, 42.7%), acute and chronic dissections (75/255, 29.4%), miscellaneous (41/255, 16.1%), and penetrating aortic ulcers (30/255, 11.8%). There were 151 males (151/255, 59.2%) and 104 females (104/255, 40.8%) with a mean age of 71 years (range, 23–91 years). Results The LSA was completely covered with an ELG in 71 patients (71/255, 27.8%) and partially covered in 47 patients (47/255, 18.4%). In patients who had complete coverage of the LSA, 30 patients (30/71, 42.3%) had acute or chronic Type B dissections, 26 patients (26/71, 36.6%) had aneurysms, 11 patients (11/71, 15.5%) had miscellaneous aortic pathologies, and 4 patients (4/71, 5.6%) had pseudoaneurysms associated with prior coarctation repair. Fifteen patients (15/255, 5.9%) underwent preoperative carotid-subclavian bypass or transposition and subsequently underwent complete coverage of the LSA with an ELG. One patient (1/56, 1.8%) with complete coverage of the LSA required elective postoperative carotid-subclavian bypass secondary to left arm claudication. Conclusions Routine preoperative carotid-subclavian bypass is not necessary, except in select patients with a patent left internal mammary artery to the left anterior descending artery bypass graft or contralateral vertebral artery disease.

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Dissection of descending aorta treated by stent-graft implantation in a patient with Marfan syndrome

Heart Vessels and Transplantation ◽

10.24969/hvt.2017.4 ◽

2017 ◽

Vol 1 (Issue 1) ◽

Author(s):

Marat Aripov ◽

Ildar Abdyldaev ◽

Semen Chevgun ◽

Bektur Daniyarov ◽

Dinara Toktosunova ◽

...

Keyword(s):

Marfan Syndrome ◽

Thoracic Aorta ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Celiac Trunk ◽

Proximal Part ◽

Left Common Iliac Artery ◽

Computer Tomography Scan ◽

Stent Graft Implantation

This report describes a 32 years old patient with Marfan syndrome and hypertension. David`s procedure was performed to the patient three months before due to dissection of the ascending thoracic aorta. Computer tomography scan showed DeBakey type III dissection of aorta beginning from left subclavian artery with transition to the ostium of the celiac trunk and proximal part of the left common iliac artery. Stent-grafts in the descending thoracic aorta with overlapping of left subclavian artery were implanted to the patient with Marfan syndrome. Patient was discharged and no complications recorded at 6th month follow-up.

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Endo and exo aortic morphometry (endoluminal) in the aortic arch and its branches

ARS Medica Tomitana ◽

10.1515/arsm-2016-0018 ◽

2016 ◽

Vol 22 (2) ◽

pp. 103-107

Author(s):

S. Malik ◽

R. Baz ◽

C. Dina ◽

P. Bordei ◽

A. Rusali ◽

...

Keyword(s):

Carotid Artery ◽

Aortic Arch ◽

Thoracic Aorta ◽

Subclavian Artery ◽

Common Carotid Artery ◽

Left Subclavian Artery ◽

Average Diameter ◽

Left Common Carotid Artery ◽

Arterial Trunk ◽

Horizontal Diameter

Abstract Our study was conducted by the examination of angioCT’s, performing external measurements of aortic arch and the exo and endoaortic measurements of its three. The diameter of the thoracic aorta prior to the origin of the brachiocephalic arterial trunk was found with an average of 31.65 mm and below the left subclavian artery origin we found an average diameter of 24.3 mm. The brachiocephalic arterial trunk had an average diameter of 11.575 mm, 6.05 at carotid artery level and 9.05 mm at the level of the left subclavian artery. The endoaortic average diameter of the brachiocephalic arterial trunk: horizontally, 13.0 mm and vertically 11.7 mm; left common carotid artery horizontal diameter was 10.5 mm and 9.7 mm vertically and the left subclavian artery have 14.1 mm horizontally and 10.8 mm vertically.

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Outcomes of Coverage of the Left Subclavian Artery during Endovascular Repair of the Thoracic Aorta

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2015.07.022 ◽

2015 ◽

Vol 26 (11) ◽

pp. 1609-1614 ◽

Cited By ~ 15

Author(s):

Benjamin N. Contrella ◽

Saher S. Sabri ◽

Margaret C. Tracci ◽

James R. Stone ◽

John A. Kern ◽

...

Keyword(s):

Thoracic Aorta ◽

Subclavian Artery ◽

Endovascular Repair ◽

Left Subclavian Artery

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Management of the Left Subclavian Artery During Endovascular Repair of the Thoracic Aorta

Journal of Endovascular Therapy ◽

10.1583/08-2406.1 ◽

2008 ◽

Vol 15 (2) ◽

pp. 168-176 ◽

Cited By ~ 53

Author(s):

Nadim Noor ◽

Umar Sadat ◽

Paul D. Hayes ◽

Matthew M. Thompson ◽

Jonathan R. Boyle

Keyword(s):

Thoracic Aorta ◽

Subclavian Artery ◽

Endovascular Repair ◽

Left Subclavian Artery

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When is extra-anatomical bypass for the left subclavian artery required to prevent ischaemia after thoracic endovascular stent grafting?

Asian Cardiovascular and Thoracic Annals ◽

10.1177/02184923211008074 ◽

2021 ◽

pp. 021849232110080

Author(s):

Katherine Moore ◽

Damian Miles Bailey ◽

Michael Howard Lewis ◽

Andrew Gordon ◽

Rhodri Thomas ◽

...

Keyword(s):

Thoracic Aorta ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Thoracoabdominal Aortic Aneurysm ◽

Aortic Disease ◽

Thoracic Aortic Disease ◽

Stent Grafting ◽

Landing Zone ◽

Presenting Symptoms ◽

Group I

Introduction Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft. Materials and methods Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement. Results Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p < 0.05. Conclusions In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).

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