Outcome after cervical debranching for proximal landing zone extension in thoracic endovascular aortic repair
Abstract Objective Aim of this study was to assess perioperative and long-term outcome after cervical debranching for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR). Methods Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between 2010 and 2019. Endpoints were patency and re-intervention due to the debranching, postoperative stroke, cranial nerve injury and mortality at 30 days and during follow-up. Results Forty-eight patients (66 ± 12 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%). Eleven (23%) patients had simultaneous emergency debranching and TEVAR. There were eight (17%) re-interventions within 30 days: four due to local hematoma, one for bypass occlusion, two for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. Thirty-day mortality was 2 %; one patient died on the first postoperative day after combined CABG surgery and multiorgan failure. Four (8%) patients suffered postoperative strokes; three occurred after simultaneous emergency procedures and none was fatal. Seven (15%) patients had postoperative ipsilateral cranial nerve lesions: two occurred after CSB and five after SCT. Two patients had recurrent laryngeal nerve palsy, two had phrenic nerve injury and three had Horner syndrome. All patients had mild symptoms and recovered mostly. During a mean follow-up of 31±29 months with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 94%, primary assisted patency 96%, and secondary patency 100%. 9 patients died during follow-up after a mean of 30±29 months (range 0-82) all of them with patent cervical debranching. Conclusion Cervical debranching for proximal landing zone extension in TEVAR is a safe procedure with an acceptable rate of early re-interventions. There is a higher risk for postoperative stroke during simultaneous emergency debranching and TEVAR. Cranial nerve injuries and hematomas remain relevant periprocedural complications. During follow-up, excellent patency can be expected.