Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization

Maldonado, Thomas S.; Dexter, David J.; Rockman, Caron; Veith, Frank J.; Garg, Karan; Arko, Frank R.; Bertoni, Hernán G.; Ellozy, Sharif H.; Jordan, William D.; Woo, Edward Y.

doi:10.1016/j.jvs.2012.06.101

Cited by 99 publications

(85 citation statements)

References 18 publications

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“…For example, Feezor et al described their experience with TEVAR and LSA coverage, and noted a reduction in stroke events from 6% down to 2% with selective revascularization. However, our results are in contrast to a contemporary study by Maldonado et al (12), that evaluated selective LSA revascularization during TEVAR patients with thoracic aortic aneurysm. This study noted a stroke rate of approximately 6%, with no difference in stroke outcomes with or without revascularization.…”

Section: Discussioncontrasting

confidence: 99%

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques

Zamor

Eskandari

Rodríguez

et al. 2015

Journal of the American College of Surgeons

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Background Practice guidelines regarding management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low quality evidence and there is limited literature that addresses optimal revascularization techniques. The purpose of this study is to compare outcomes of LSA coverage during TEVAR and revascularization techniques. Study Design We performed a single-center retrospective cohort study from 2001–2013. Patients were categorized by LSA revascularization and by revascularization technique, carotid-subclavian bypass (CSB) or subclavian-carotid transposition (SCT). Thirty-day and mid-term stroke, spinal cord ischemia, vocal cord paralysis, upper extremity ischemia, primary patency of revascularization, and mortality were compared. Results Eighty patients underwent TEVAR with LSA coverage, 25% (n=20) were unrevascularized and the remaining patients underwent CSB (n=22, 27.5%) or SCT (n=38, 47.5%). Mean follow-up time was 24.9 months. Comparisons between unrevascularized and revascularized patients were significant for a higher rate of 30-day stroke (25% vs. 2%, p=0.003) and upper extremity ischemia (15% vs. 0%, p=0.014). However, there was no difference in 30-day or mid-term rates of spinal cord ischemia, vocal cord paralysis, or mortality. There were no statistically significant differences in 30-day or midterm outcomes for CSB vs. SCT. Primary patency of revascularizations was 100%. Survival analysis comparing unrevascularized vs. revascularized LSA, was statistically significant for freedom from stroke and upper extremity ischemia, p=0.02 and p=0.003, respectively. After adjustment for advanced age, urgency and coronary artery disease, LSA revascularization was associated with lower rates of peri-operative adverse events (OR 0.23, p=0.034). Conclusions During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.

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Section: Discussioncontrasting

confidence: 99%

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques

Zamor

Eskandari

Rodríguez

et al. 2015

Journal of the American College of Surgeons

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“…40,42 During endovascular repair, guidewires within the aortic arch have the potential to mobilize debris and guidewire manipulation should be reduced to the minimum. According to a recent retrospective, multicentre analysis of selective LSA revascularisation in the treatment of multiple DTA pathologies, 48 coverage of the LSA in patients treated with TEVAR was associated with a higher incidence of stroke and paraplegia. Therefore, LSA revascularisation should be considered in the elective setting.…”

Section: Prevention Of Spinal Cord Ischaemia In Open Repairmentioning

confidence: 99%

Editor's Choice – Management of Descending Thoracic Aorta Diseases

Riambau¹,

Böckler²,

Brunkwall³

et al. 2017

European Journal of Vascular and Endovascular Surgery

957

259

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“…Studies in support of routine preoperative LSA revascularisation show that the coverage of the LSA during TEVAR is associated with an increased risk of stroke, paraplegia and arm ischaemia. Other studies have shown that coverage of the LSA without prophylactic revascularisation is not associated with increased morbidity, supporting those results promoting selective LSA revascularisation during TEVAR [7, 12–14]. In this study, we analysed the consequences of intentional LSA coverage during TEVAR with special attention to the development of neurologic complications in a real life, non-selected (“all comers”) population.…”

Section: Introductionmentioning

confidence: 58%

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

Wojciechowski

Znaniecki

Bury

et al. 2014

Langenbecks Arch Surg

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BackgroundThe management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate.Materials and methodsA retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm.ResultsOf the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2–64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A.ConclusionOur analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.

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Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization

Cited by 99 publications

References 18 publications

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques

Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques

Editor's Choice – Management of Descending Thoracic Aorta Diseases

Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation—early and midterm results

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