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

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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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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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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Association of left subclavian artery coverage without revascularization and spinal cord ischemia in patients undergoing thoracic endovascular aortic repair: A Vascular Quality Initiative® analysis

Vascular ◽

10.1177/1708538116681910 ◽

2017 ◽

Vol 25 (6) ◽

pp. 587-597 ◽

Cited By ~ 16

Author(s):

Pedro GR Teixeira ◽

Karen Woo ◽

Adam W Beck ◽

Salvatore T Scali ◽

Fred A Weaver ◽

...

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia ◽

Multivariable Analysis ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Aortic Repair

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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Hypogastric Artery Stenting for Chronic Intermittent Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair

Journal of Endovascular Therapy ◽

10.1177/1526602820925445 ◽

2020 ◽

Vol 27 (5) ◽

pp. 801-804

Author(s):

Catharina Gronert ◽

Nikolaos Tsilimparis ◽

Giuseppe Panuccio ◽

Ahmed Eleshra ◽

Fiona Rohlffs ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Ischemia ◽

Thoracic Endovascular Aortic Repair ◽

Neurological Symptoms ◽

Endovascular Aortic Repair ◽

Hypogastric Artery ◽

Lower Extremity Weakness ◽

Aortic Repair ◽

The Right

Purpose: To report a case of chronic intermittent spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and its successful treatment using hypogastric artery stenting. Case Report: A 79-year-old patient presented in May 2013 with a thoracic aortic aneurysm (TAA) and a contained rupture. He urgently underwent TEVAR that covered 274 mm of descending thoracic aorta without immediate postoperative signs of acute SCI. At 3-month follow-up, he reported repeating incidents of sudden lower extremity weakness leading to a fall with a humerus fracture. A neurological consultation revealed the tentative diagnosis of intermittent SCI caused by TEVAR and initially recommended a conservative approach. During the following year there was no clinical improvement of the symptoms. Computed tomography angiography showed a high-grade stenosis of the right hypogastric artery, which was stented in November 2014 to improve the collateral network of spinal cord perfusion. Following treatment, the patient had no further neurological symptoms; at 32 months after the reintervention, the imaging follow-up documented a patent stent and continued exclusion of the TAA. Conclusion: Intermittent neurological symptoms after TEVAR should be suspected as chronic intermittent SCI. The improvement of collateral networks of the spinal cord by revascularization of the hypogastric artery is a viable treatment option.

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Successful Endovascular Repair of a Kommerell’s Diverticulum and a Right-Sided Aortic Arch

The Heart Surgery Forum ◽

10.1532/hsf.3267 ◽

2020 ◽

Vol 23 (6) ◽

pp. E860-E862

Author(s):

Masato Hayakawa ◽

Takaaki Nagano ◽

Isao Nishijima ◽

Kento Shinzato ◽

Ryo Ikemura ◽

...

Keyword(s):

Computed Tomography ◽

Case Report ◽

Aortic Arch ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Right Aortic Arch ◽

Maximum Diameter ◽

Kommerell’S Diverticulum

Background: A 57-year-old woman was diagnosed with Kommerell’s diverticulum in the setting of a right aortic arch on computed tomography. Case report: Although asymptomatic, the maximum diameter of the aneurysm was 55 mm; thus, she underwent surgery to prevent rupture of the aneurysm. A bypass was constructed from the left common carotid artery to the left subclavian artery. A stent-graft was deployed from the distal right subclavian artery, and coil embolization of the diverticulum was performed via the left subclavian artery. She was discharged after 12 days of surgery. The postoperative four-month follow up showed a smaller aneurysm. Conclusion: Thoracic endovascular aortic repair is feasible and effective for Kommerell’s diverticulum.

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Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2

Journal of Endovascular Therapy ◽

10.1177/1526602818802581 ◽

2018 ◽

Vol 25 (6) ◽

pp. 740-749 ◽

Cited By ~ 6

Author(s):

Gabriele Piffaretti ◽

Giovanni Pratesi ◽

Guido Gelpi ◽

Mario Galli ◽

Frank J. Criado ◽

...

Keyword(s):

Subclavian Artery ◽

Left Subclavian Artery ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Entire Group ◽

Aortic Repair ◽

Significant Difference ◽

Type Ia ◽

Related Mortality

Purpose: To analyze the results of isolated left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) using carotid-subclavian bypass (CSbp) or chimney grafts (CGs). Methods: A retrospective multicenter, observational study identified 73 patients (mean age 68±13 years, range 22–87; 56 men) with acute or chronic thoracic aortic lesions who underwent TEVAR with isolated LSA revascularization using either CSbp (n=42) or CGs (n=31) from January 2010 and February 2017. Primary endpoints were TEVAR-related mortality, postoperative stroke, freedom from type Ia endoleak, and LSA patency. Results: Primary technical success was achieved in all cases. Early TEVAR-related mortality was 4.2% (CSbp 2% vs CG 6%, p=0.571). Two (3%) patients had major ischemic strokes (one in each group). Mean follow-up was 24±21 months (range 1–72; median 15). Estimated freedom from TEVAR-related mortality was 93%±3% (95% CI 84.3% to 97.0%) at 12 and 36 months, with no significant difference between CSbp and CG (p=0.258). Aortic reintervention did not differ between the groups (CSbp 5% vs CG 6%, p=0.356); nor did freedom from type Ia endoleak (CSbp 98% vs CG 87%, p=0.134). Gutter-related endoleaks occurred in 4 (13%) CG patients, but none of the patients experienced sac enlargement or the need for reintervention and none died. Primary patency of the LSA was 100% for the entire group during the observation period. Conclusion: In our experience, LSA revascularization proved most satisfactory and equally effective with both the CSbp and CG techniques, without discernible differences at midterm follow-up.

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

Journal of Vascular Surgery ◽

10.1016/j.jvs.2015.04.379 ◽

2015 ◽

Vol 61 (6) ◽

pp. 201S

Author(s):

Pedro G. Teixeira ◽

Karen Woo ◽

Adam W. Beck ◽

Salvatore T. Scali ◽

Fred A. Weaver

Keyword(s):

Spinal Cord ◽

Subclavian Artery ◽

Left Subclavian Artery ◽

Spinal Cord Ischemia

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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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Midterm outcomes of fenestrated TEVAR using physician-modified endovascular grafts for zone 2

Vascular ◽

10.1177/17085381211019611 ◽

2021 ◽

pp. 170853812110196

Author(s):

Jiaxue Bi ◽

Fang Niu ◽

Peng Li ◽

Xiangchen Dai ◽

Jiechang Zhu ◽

...

Keyword(s):

Subclavian Artery ◽

Left Subclavian Artery ◽

Perioperative Complications ◽

Thoracic Endovascular Aortic Repair ◽

Endovascular Aortic Repair ◽

Landing Zone ◽

Aortic Repair ◽

Primary Endpoints ◽

Endovascular Grafts

Objectives To summarize the experience and midterm outcomes of physician-modified endovascular grafts for zone 2 thoracic endovascular aortic repair. Methods A retrospective analysis was conducted of 51 consecutive patients (mean age 57.6 ± 12.5 years, 39 males) treated with thoracic endovascular aortic repair using physician-modified endovascular grafts for reconstructing the left subclavian artery from November 2015 to December 2019. The primary endpoints during follow-up were the overall mortality, aorta-related mortality, and major complications. The secondary endpoints were reintervention and the patency of the target branches, the demographics and technical details were also described and analyzed. Results Sixty-three thoracic stent-grafts were deployed in 51 patients and emergency surgery was performed in 10 patients (19.6%). Technical success was 94.1% (48/51). The incidence of perioperative complications was 15.7%, and the 30-day mortality was 0%. At a mean follow-up of 42.0 ± 14.4 months (range, 14–63 months), all the left subclavian arteries remained patent. All-cause mortality was 3.9% (2/51) and not aorta-related deaths. Estimated survival at one and three years was 98.0 ± 1.9% and 96.0 ± 2.8%, respectively. Conclusions The physician-modified endovascular grafts is feasible and effective to preserve left subclavian artery in thoracic endovascular aortic repair for aortic arch pathologies with unhealthy proximal landing zone.

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

Aorta ◽

10.1055/s-0040-1715608 ◽

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.

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