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.

Introduction The management of Kommerell’s Diverticulum (KD) has evolved from open surgical resection and graft replacement of the aorta, to endovascular repair in asymptomatic patients due to its recognized possible sequelae – aortic rupture and dissection. Despite these technical advances, standard indications for intervention and treatment algorithms remain unclear. We will present our single-center experience in the treatment of KD, supporting a multidisciplinary endovascular-first approach. Methods All patients who underwent thoracic endovascular aortic repair (TEVAR) for KD between 2017 and 2020 were retrospectively identified from a prospectively maintained institutional surgery database. Chart review was used to characterize presenting symptoms, interventions, technical results, and complications. Revascularization was performed using carotid-axillary bypass. Routine endovascular subclavian artery occlusion was employed to eliminate retrograde diverticulum perfusion and avoid open ligation. Results 8 patients were identified, including 6 females and 2 males between the ages of 44-76. Patients presented with dysphagia (n = 3), acute embolic stroke (n = 1), transient ischemic attack (TIA) (n = 1), upper extremity embolization (n = 1), and acute type B aortic dissection (n = 1). One patient had a prior incomplete open repair that was successfully treated endovascularly. Another patient had a mediastinal neoplasm infiltrating an incidental aberrant subclavian artery and KD. All cases had symptomatic improvement and successful endovascular repair as demonstrated on post-operative imaging. Perioperative complications included percutaneous access site pseudoaneurysm (n = 2), stroke (n = 1), and subclavian artery rupture immediately recognized and treated (n = 1). There was no perioperative mortality. Conclusion Endovascular techniques have resulted in technical success and symptomatic improvement for KD without open thoracotomy or sternotomy. Significant rates of endovascular complications and paucity of long-term durability data should be considered. Until formal criteria for repair are established, early application of TEVAR using a consistent multi-specialty approach may mitigate the risk of unpredictable aortic complications in these patients while avoiding the accepted morbidity and mortality of open surgery.

used to calculate adjusted 30-day mortality and long-term survival, respectively.Results: A total of 1832 patients underwent AAA repair from 2005 to 2015. Baseline characteristics were similar across MDI quintiles with the exception of coronary disease and peripheral vascular disease (Table ). The 30-day outcomes were similar across MDI quintiles (Table ). Univariable regression revealed no difference in 30-day mortality across MDI quintiles (P ¼ NS) but did find age >70 years (odds ratio [OR], 2.17; 95% confidence interval [CI]. 1.37-3.43; P ¼ .001), female sex (OR, 1.58; 95% CI, 1.01-2.48; P ¼ .044), history of stroke (OR, 2.28; 95% CI, 1.31-3.96; P ¼ .003), and endovascular approach (EVAR) (OR, 0.20; 95% CI, 0.10-0.42; P < .001) to significantly impact 30-day mortality. Multivariable analysis revealed age >70 years (OR, 2.41; 95% CI, 1.51-3.84; P < .001), history of stroke (OR, 2.21; 95% CI, 1.27-3.94; P ¼ .006), and EVAR (OR, 0.18; 95% CI, 0.09-0.38; P < .001), but not MDI (P ¼ NS) or sex (P ¼ NS) to be associated with increased 30-day mortality. There was no effect of MDI quintile on long term survival on univariable analysis, and after adjusting after age, sex, chronic obstructive pulmonary disease status, and EVAR (Figure ).Conclusions: SES does not appear to affect short nor long term mortality after AAA repair in a publicly funded health care system.

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AVF, Arteriovenous fistula; AVG, arteriovenous graft; COPD, chronic obstructive pulmonary disease; HIV, human immunodeficiency virus; IVDU, intravenous drug use; PAD, peripheral arterial disease. Categorical and continuous variable are reported as No. (%) and mean (standard deviation), respectively.