Outcome after Thoracic Endovascular Aortic Repair with Complete or Partial Stent Graft Coverage of the Left Subclavian Artery

Objectives: To evaluate the outcome after thoracic endovascular aortic repair (TEVAR) with complete or partial coverage of the left subclavian artery (LSA).

Methods: Between 08/2001 and 10/2016, a total of 237 patients (171 males; mean age 63 ± 15.2 years) were treated by TEVAR with complete (group 1; n = 204) or partial (group 2;n = 33) LSA coverage. In group 1, supraaortic revascularization (SAR) was performed prior to TEVAR in 81 (34.2%) cases (subgroup 1a) - incl. complete debranching (n = 16;6.8%), LSA-to-left common carotid (LCCA) bypass/transposition (n = 60; 25%), LCCA-to-right common carotid bypass (n = 4; 1.7%) and Chimney technique (n = 4; 1.7%), while 123 (52%) patients received no SAR (subgroup 1b). Landing zones: 0 (n = 17; 7.2%), 1 (n = 6; 2.5%) and 2 (214; 90.3%).

Results: Median follow-up time (entire cohort) was 17 months (IQR: 1.2–49.0). In-hospital and overall mortality for group 1 vs 2 were 10.3% vs 9.1% (p = 1.000) and 11.8% versus 6.1% (p = 0.547). Median ICU and hospital stay were 5.9 (IQR: 1.0–6.0) vs 4.9 (IQR: 1.0–5.0) and 16.7 (IQR:7.0–20.0) vs 11.7 (IQR:5.0–15.) days (group 1 vs. 2). Estimated survival of the study cohort (n = 237) was 83.4 ± 2.6% (1yr), 80.4 ± 2.9% (3yrs) and 73.9 ± 3.7% (5yrs). Postoperative complications - incl. stroke (n = 19; 8%), paraplegia (n = 14; 5.9%), endoleak (n = 43; 18.1%), renal insufficiency (n = 15; 6.3%), sepsis (n = 8; 3.4%) and multi-organ failure (n = 10; 4.2%) - and required reoperations (open/endovascular) were not significantly different between both groups. Respiratory insufficiency was significantly higher in group 1 vs 2 (21.6% vs 6.1%; p = 0.0345). Subgroup analysis (1a vs 1b) showed significantly higher incidences of prolonged ventilation (0% vs 11.4%;p = 0.0001), tracheostomy (4.9% vs 11.4%;p = 0.042), left arm malperfusion (1.2% vs 8.9%;p = 0.0002) and need for open revascularization (0% vs 4.9%; p = 0.0067) in patients without SAR (subgroup 1b). However, a trend toward more endovascular reinterventions was observed in subgroup 1a (16% vs 7.3%; p = 0.0645). Independent from study groups, the incidence of paraplegia was significantly associated with the use of >2 aortic stent grafts (p = 0.0388).

Conclusion: TEVAR with either complete or partial LSA coverage may be performed with acceptable early and mid-term mortality. However, to avoid paraplegia as a major complication—especially if TEVAR is extended to the distal descending aorta—SAR of the LSA (with other neuroprotective measures) is recommended to ensure antegrade perfusion of the spinal collateral network.