Carotid-axillary bypass as an alternative revascularization method for zone II thoracic endovascular aortic repair

The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection

“…The data in that analysis did not support LSA revascularization for stroke prevention, and other large data sets, including the National Surgical Quality Improvement Program registry, 170 and prior meta-analyses [171][172][173] have found no benefit with regard to stroke prevention for LSA revascularization in patients undergoing zone 2 TEVAR, perhaps because strokes during zone 2 TEVAR are generally embolic in nature. 174 Currently available techniques for LSA revascularization in conjunction with TEVAR include surgical carotidsubclavian bypass, 175 carotid-subclavian transposition, 176 and carotid-axillary bypass, 177 along with endovascular techniques, including chimney grafts, scallops, fenestrated grafts, and branched grafts. 178 Surgical revascularization techniques are associated with not insignificant risks of phrenic and recurrent laryngeal nerve palsy, 175 although these risks may be decreased with carotid-axillary bypass 177 due to avoidance of any manipulation in the vicinity of the phrenic nerve.…”

“…174 Currently available techniques for LSA revascularization in conjunction with TEVAR include surgical carotidsubclavian bypass, 175 carotid-subclavian transposition, 176 and carotid-axillary bypass, 177 along with endovascular techniques, including chimney grafts, scallops, fenestrated grafts, and branched grafts. 178 Surgical revascularization techniques are associated with not insignificant risks of phrenic and recurrent laryngeal nerve palsy, 175 although these risks may be decreased with carotid-axillary bypass 177 due to avoidance of any manipulation in the vicinity of the phrenic nerve. Carotid-subclavian transposition should be avoided in patients with a patent pedicled left internal mammary artery bypass graft due to the risk of myocardial ischemia during the mandatory period of proximal LSA clamp with this procedure.…”

“…Carotid-subclavian transposition should be avoided in patients with a patent pedicled left internal mammary artery bypass graft due to the risk of myocardial ischemia during the mandatory period of proximal LSA clamp with this procedure. 177 Although limited long-term data are available, late revascularization patency may be superior with carotid-subclavian transposition 176 compared with the bypass techniques. 175,177 Recent data from the Society for Vascular Surgery Vascular Quality Initiative 178 comparing open surgical and endovascular LSA revascularization techniques in 837 patients during zone 2 TEVAR found similar perioperative outcomes for open vs endovascular revascularization.…”

Endovascular Repair of Aortic Dissection Involving the Left Subclavian Artery by Castor Stent Graft: A Multicentre Prospective Trial

“…Bypass related complications exist at low rates: unplanned return to the operating room (reported rate 2.8%: 2.1% for haematoma evacuation and 0.7% for management of chylous leak); sustained nerve injury (2.1%); vertebral artery occlusion (6%); and failure in primary patency during follow up (the one, two, and five year primary patency rates are reported to be 99.5%, 98.9%, and 98.0%, respectively). 19,20 Endovascular reconstruction of the LSA has long been explored, and recently reported to be equally effective as bypass procedure. 21 Chimney techniques and fenestrated devices have been used to treat some patients with aortic dissection involving the LSA.…”

Current state of hybrid solutions for aortic arch aneurysms

“…In certain cases, the left subclavian artery (LSA) may not be readily accessible via a sternotomy approach due to distal takeoff from the arch, in which case type I HAR may involve only debranching of the innominate and left common carotid arteries from the ascending aorta, with the LSA revascularized via a carotid-subclavian bypass (8) (Figure 2) or transposition (9), carotid-axillary bypass (10), or alternatively via a transthoracic aorta to infraclavicular axillary artery bypass (Figure 3, left panel).…”