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Thorac Cardiovasc Surg
DOI: 10.1055/a-2125-3173
Original Cardiovascular

Urgent Endovascular Aortic Repair Requiring Coverage of the Left Subclavian Artery

Peter L. Haldenwang 
1   Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
,
Christoph Heute
2   Institute for Radiologic Diagnostics, Interventional Radiology and Nuclear Medicine, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
,
Karla J. Schero
3   Institute for Diagnostic and Interventional Radiology and Nuclear Medicine, Marien Hospital Herne, Academic Teaching Hospital of the University Bochum, Herne, Nordrhein-Westfalen, Germany
,
Markus Schlömicher
1   Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
,
Lorine Haeuser
4   Department of Urology and Neuro-Urology, Marien Hospital Herne Academic Teaching Hospital of the University Bochum, Herne, Nordrhein-Westfalen, Germany
,
Volkmar Nicolas
2   Institute for Radiologic Diagnostics, Interventional Radiology and Nuclear Medicine, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
,
Justus T. Strauch
1   Department of Cardiothoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Nordrhein-Westfalen, Germany
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Abstract

Background Evaluation of the optimal left subclavian artery (LSA) management during thoracic endovascular aortic repair (TEVAR) involving the distal aortic arch in an urgent setting.

Methods A total of 52 patients with acute aortic syndromes underwent TEVAR (March 2017 to May 2021) requiring proximal landing in the distal aortic arch. Decision for partial or complete LSA ostial endograft coverage, with or without additional bypassing, was made depending upon the aortic pathology and vascular anatomy. We focused on the patency of the circle of Willis and the unilateral dominance of one carotid or a vertebral artery: 35% underwent complete (complete LSA group) and 17% partial LSA coverage (partial LSA group), whereas in 48% the LSA was reached only by the bare springs of the endograft (control group). A total of 22% of the complete LSA group underwent LSA bypass before TEVAR, whereas 11% underwent cerebrospinal fluid drainage. Endpoints were 30-day and 1-year mortality, stroke, spinal cord ischemia (SCI), and malperfusion.

Results Technical success was achieved in 96%. The endograft length was 171 ± 34 (complete LSA group) versus 151 ± 22 (partial LSA group) versus 181 ± 52 mm (control group), covering 6 ± 2 versus 5 ± 1 versus 7 ± 2 intercostal arteries. The 30-day mortality, stroke and SCI rates did not differ. One patient with arm malperfusion underwent LSA bypass post-TEVAR. After 1 year, aortic interventions occurred in 6 (complete LSA group) versus 22 (partial LSA group) versus 13% (control group). One-year mortality (0 vs. 0 vs. 8%), stroke (6 vs. 0 vs. 4%), and SCI (0 vs. 0 vs. 4%) were similar between groups.

Conclusion With an adequate analysis of vascular anatomy, coverage of the LSA for TEVAR is safe and may offer results similar to TEVAR starting distal to the LSA.

Keywords

Aorta - aortic computed tomography (CAT scan) - Endovascular procedures - stents except PCI - imaging (all modalities)


Publication History

Received: 02 March 2023

Accepted: 04 July 2023

Accepted Manuscript online:
07 July 2023

Article published online:
16 October 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Erbel R, Aboyans V, Boileau C. et al; ESC Committee for Practice Guidelines, The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
    CrossrefPubMedSearch in Google Scholar
  • 2 Delafontaine JL, Hu B, Tan TW. et al. Outcome comparison of TEVAR with and without left subclavian artery revascularization from analysis of nationwide inpatient sample database. Ann Vasc Surg 2019; 58: 174-179
    CrossrefPubMedSearch in Google Scholar
  • 3 Mitchell RS, Ishimaru S, Ehrlich MP. et al. First international summit on thoracic aortic endografting: roundtable on thoracic aortic dissection as an indication for endografting. J Endovasc Ther 2002; 9 (Suppl. 02) II98-II105
    CrossrefPubMedSearch in Google Scholar
  • 4 Khachatryan Z, Haunschild J, von Aspern K, Borger MA, Etz CD, Etz CD. Ischemic spinal cord injury-experimental evidence and evolution of protective measures. Ann Thorac Surg 2022; 113 (05) 1692-1702
    CrossrefPubMedSearch in Google Scholar
  • 5 Wong CS, Healy D, Canning C, Coffey JC, Boyle JR, Walsh SR. A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting. J Vasc Surg 2012; 56 (05) 1438-1447
    CrossrefPubMedSearch in Google Scholar
  • 6 Chaudhary O, Sharkey A, Schermerhorn M. et al. Protocolized based management of cerebrospinal fluid drains in thoracic endovascular aortic aneurysm repair procedures. Ann Vasc Surg 2021; 72: 409-418
    CrossrefPubMedSearch in Google Scholar
  • 7 Etz CD, Debus ES, Mohr FW, Kölbel T. First-in-man endovascular preconditioning of the paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury. J Thorac Cardiovasc Surg 2015; 149 (04) 1074-1079
    CrossrefPubMedSearch in Google Scholar
  • 8 Luehr M, Etz CD, Berezowski M. et al. Outcomes after thoracic endovascular aortic repair with overstenting of the left subclavian artery. Ann Thorac Surg 2019; 107 (05) 1372-1379
    CrossrefPubMedSearch in Google Scholar
  • 9 Conway AM, Qato K, Nhan Nguyen Tran N, Giangola G, Carroccio A. Management of the left subclavian artery in TEVAR for chronic type B aortic dissection. Vasc Endovascular Surg 2020; 54 (07) 586-591
    CrossrefPubMedSearch in Google Scholar