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

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).

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR

2020 ◽  
pp. 153857442098365
Author(s):  
Michael H. Parker ◽  
Dayle K. Colpitts ◽  
Genevieve F. Gilson ◽  
Liam Ryan ◽  
Dipankar Mukherjee
Keyword(s):  
Subclavian Artery ◽  
Phrenic Nerve ◽  
Nerve Palsy ◽  
Left Subclavian Artery ◽  
Vascular Complications ◽  
Complication Rates ◽  
Nerve Injuries ◽  
Phrenic Nerve Palsy ◽  
Safe Alternative ◽  
Landing Zone

Introduction: Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%—specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. Methods: All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. Results: 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). Conclusion: Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

scholarly journals Blunt Traumatic Aortic Injury: 10-Year Single-Center Experience

Aorta ◽  
2021 ◽  
Author(s):  
Ahmet Can Topcu ◽  
Kamile Ozeren-Topcu ◽  
Ahmet Bolukcu ◽  
Sinan Sahin ◽  
Avni U. Seyhan ◽  
...  
Keyword(s):  
Thoracic Aorta ◽  
Subclavian Artery ◽  
Open Repair ◽  
Left Subclavian Artery ◽  
Aortic Injury ◽  
Blunt Thoracic Aortic Injury ◽  
Phone Calls ◽  
Primary Treatment Modality ◽  
Thoracic Aortic Injury

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.

Complications after Endovascular Repair of Type B Aortic Dissection

2002 ◽  
Vol 9 (6) ◽  
pp. 822-828 ◽  
Author(s):  
Reinhard S. Pamler ◽  
Thomas Kotsis ◽  
Johannes Görich ◽  
Xaver Kapfer ◽  
Karl-Heinz Orend ◽  
...  
Keyword(s):  
Aortic Dissection ◽  
Stent Graft ◽  
Subclavian Artery ◽  
Left Subclavian Artery ◽  
Type B ◽  
Type B Aortic Dissection ◽  
Stent Grafting ◽  
Stent Graft Implantation ◽  
Graft Implantation

Purpose: To outline the complications encountered after endoluminal treatment in patients with type B aortic dissection. Methods: Between 1999 and 2001, 14 patients (12 men; mean age 60.3 years, range 39–79) with isolated type B aortic dissection (13 chronic, 1 acute) underwent aortic stent-grafting. Three patients with chronic dissection presented an acute clinical picture and were managed emergently. The left subclavian artery was intentionally covered by the prosthesis in 9 patients. Follow-up studies were performed at 6-month intervals. Results: Stent-graft implantation was technically successful in all patients, but incomplete sealing (endoleak) of the entry site required additional proximal stent-graft implantation in 4. The left subclavian artery remained patent in 5 patients. Secondary conversion was required in 3 patients: 2 for acute type A dissection resulting from injury to the aortic arch by Talent endografts and a sustained hemorrhage (left hemothorax). In another patient, a secondary intramural hematoma subsided spontaneously. Anterior spinal artery syndrome in 1 patient persisted at 1 month. No bypass was necessary for the 9 patients with the covered left subclavian arteries. Mean follow-up was 14 months (range 1–23). Conclusions: Stent-grafting is feasible in patients with type B aortic dissection, although it is associated with a considerable rate of complications. Frank reporting of these sequelae for a variety of stent-grafts is of paramount importance to clarifying the limitations of the method.

Surgical bypass from the left common carotid artery to the left subclavian artery: Central approach

2021 ◽  
Keyword(s):  
Carotid Artery ◽  
Subclavian Artery ◽  
Common Carotid Artery ◽  
Left Subclavian Artery ◽  
Thoracic Endovascular Aortic Repair ◽  
Left Common Carotid Artery ◽  
Aortic Diseases ◽  
Landing Zone ◽  
Surgical Bypass ◽  
Aneurysm Dissection

To create an optimal landing zone (zone 2) in the aortic arch for concomitant or subsequent thoracic endovascular aortic repair of aortic diseases (aneurysm, dissection), surgeons frequently need to debranch the supra-aortic vessels. We present a surgical debranching of the left subclavian artery by performing a centrally located bypass from the left common carotid artery to the left subclavian artery.

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

2008 ◽  
Vol 3 (3) ◽  
pp. 147-150 ◽  
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.

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

2011 ◽  
Vol 39 (4) ◽  
pp. 507-518 ◽  
Author(s):  
Syed M. Rehman ◽  
Joshua A. Vecht ◽  
Ryan Perera ◽  
Rozh Jalil ◽  
Srdjan Saso ◽  
...  
Keyword(s):  
Thoracic Aorta ◽  
Subclavian Artery ◽  
Left Subclavian Artery ◽  
Endovascular Stenting
Sign in / Sign up

Export Citation Format

Share Document