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.

No conflict of interest has been declared by the author(s).