RR24. Association of Left Subclavian Artery Coverage Without Revascularization and Spinal Cord Ischemia in Patients Undergoing TEVAR

Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011–July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82–2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03–5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74–3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

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Left Subclavian Artery Revascularization in Thoracic Endovascular Aortic Repair: Single Center’s Clinical Experiences From 171 Patients

10.21203/rs.3.rs-451854/v1 ◽

2021 ◽

Author(s):

Wei Xie ◽

Yunxing Xue ◽

Shuchun Li ◽

Min Jin ◽

Qing Zhou ◽

...

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Retrospective Cohort ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Survival Rates ◽

Thoracic Endovascular Aortic Repair ◽

Clinical Experiences ◽

Extremity Ischemia

Abstract Background: Left 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.Methods: We 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.Results: 171 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 vs F-TEVAR. During a mean follow-up time of 24.8 months, estimates survival rates had no difference.Conclusions: LSA 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.

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

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01593-w ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Wei Xie ◽

Yunxing Xue ◽

Shuchun Li ◽

Min Jin ◽

Qing Zhou ◽

...

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Retrospective Cohort ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Survival Rates ◽

Thoracic Endovascular Aortic Repair ◽

Clinical Experiences ◽

Extremity Ischemia

Abstract Background Left 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. Methods We 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. Results 171 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. Conclusions LSA 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.

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Hybrid versus in vitro fenestration for preserving the left subclavian artery in patients undergoing thoracic endovascular aortic repair with unfavorable proximal landing zone

Vascular ◽

10.1177/1708538119862952 ◽

2019 ◽

Vol 28 (1) ◽

pp. 42-47

Author(s):

Maohua Wang ◽

Dianning Dong ◽

Hai Yuan ◽

Mo Wang ◽

Xuejun Wu ◽

...

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Landing Zone ◽

Procedural Success

Purpose To compare hybrid and in vitro fenestration procedures for preserving the left subclavian artery in thoracic endovascular aortic repair (TEVAR) with unfavorable proximal landing zone. Methods Retrospective comparison of data from 49 consecutive patients who underwent left subclavian artery revascularization during TEVAR by either hybrid or fenestration approaches from January 2015 to March 2018. Procedural duration, and 30-day rates of procedural success, mortality and complications (endoleaks, cerebral infarction, spinal cord ischemia, left arm ischemic symptoms, and delirium) were compared. Results For hybrid procedure ( n = 32) vs. fenestration ( n = 17) groups, which were age and gender matched: procedural success rate was 100%, with significantly longer procedural duration (248.4 ± 40.9 vs. 60.6 ± 16.8 min; t = –22.653, P = 0.000) and similar 30-day complication rate (18.8% vs. 11.8%; χ2 = 0.397, P = 0.529). At 12.7 ± 9.3 months’ follow-up, there were no cases of death, spinal cord ischemia, or other complications in either group. Conclusions In this retrospective, single-center comparison, both hybrid and in vitro fenestration approaches for reconstructing the left subclavian artery in TEVAR with unfavorable proximal landing zone appeared safe and effective, with shorter procedural duration for fenestration. Larger studies with longer term follow-up are warranted.

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

Egyptian Journal of Radiology and Nuclear Medicine ◽

10.1186/s43055-021-00654-3 ◽

2021 ◽

Vol 52 (1) ◽

Author(s):

Mohamed Abd El-Monem Abd El-Salam Rizk ◽

Mohamed Ismail Mohamed Ismail ◽

Kareem Sabry Gohar

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Upper Limb ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Case Series ◽

Limb Ischemia ◽

Spinal Fluid ◽

Case Series Study ◽

Sealing Zone

Abstract Background We 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. Results This 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. Conclusion By 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.

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Hypogastric and subclavian artery patency affects onset and recovery of spinal cord ischemia associated with aortic endografting

Journal of Vascular Surgery ◽

10.1016/j.jvs.2013.07.007 ◽

2014 ◽

Vol 59 (1) ◽

pp. 89-95 ◽

Cited By ~ 88

Author(s):

Matthew J. Eagleton ◽

Samir Shah ◽

Dan Petkosevek ◽

Tara M. Mastracci ◽

Roy K. Greenberg

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Spinal Cord Ischemia

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Bilateral cerebellar, left lateral medulla, and spinal cord infraction caused by idiopathic dissection of left subclavian artery

Nosotchu ◽

10.3995/jstroke.10903 ◽

2021 ◽

Author(s):

Tetsundo Yano ◽

Yukiko Maeda ◽

Katsuyoshi Ishikura ◽

Naoya Fukushima ◽

Shigeo Akiyama ◽

...

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Left Subclavian Artery

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

Vascular and Endovascular Surgery ◽

10.1177/1538574420942353 ◽

2020 ◽

Vol 54 (7) ◽

pp. 586-591

Author(s):

Allan M. Conway ◽

Khalil Qato ◽

N. Nhan Nguyen Tran ◽

Gary Giangola ◽

Alfio Carroccio

Keyword(s):

Aortic Dissection ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Type B ◽

Type B Aortic Dissection ◽

Chronic Type ◽

Perioperative Morbidity ◽

P 16 ◽

Aneurysm Diameter

Objectives: 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. Methods: 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. Results: 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). Conclusions: 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.

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