Management of Left Subclavian Artery in Endovascular Stent-Grafting for Distal Aortic Arch Disease

Abstract

linically, intentional occlusion of the left subclavian artery (LSA) has been done to exclude a distal aortic arch aneurysm during endovascular stentgrafting. [1][2][3][4][5] However, the LSA is crucial for patients with critically stenosed carotid or vertebral arteries or a functionally compromised circle of Willis, and also for those who have undergone coronary artery bypass grafting using the left internal thoracic artery (LITA). We have attempted to save the LSA by using hand-made fenestrated stent grafts, which facilitate stent-graft placement in the aortic arch without necessitating bypass-grafting to the LSA; however, because of the complex configurations of aortic disease, the LSA cannot always be saved by this technique. In our institution, a LSA occlusion test is used and when the results indicate no adverse effects from loss of the LSA, intentional LSA occlusion can be an option. We report our strategy for dealing with the LSA during endovascular stent-grafting for distal aortic arch diseases. hand-made stents. From among these, 40 cases (28.6%) in which the stent grafts were placed proximal to the LSA (zone 0-2) 6 became the subject of this study (Table 1). The patients, aged 17-92 years (mean 71.6), consisted of 36 males and 4 females. Emergency stent-grafting was performed in 9 cases (22.5%). MethodsSurgery was performed in an operating room with mobile digital subtracted angiography (DSA) available. Patients were placed on a radiolucent operating table under general intubated anesthesia. The stent graft is custom-made 7 and reconstructed by suturing graft material (Ube Corp, Ube, Japan) to an endoskeleton of Gianturco Z stents (Cook Inc, Bloomington, IN, USA). Z-stents are attached to each other using stainless steel wires with solder, leaving spaces of 8- For all 31 elective cases, the LSA occlusion test using a balloon catheter was preoperatively performed to predict critical complications secondary to LSA coverage by a stent graft and this revealed 2 cases in which the LSA was crucial for brain circulation (6.5%). The LSA was saved by using a hand-made fenestrated stent graft without bypass-grafting to the LSA in 22 cases. Bypass-grafting to LSA was performed in 5 cases. The LSA was simply occluded in 13 cases. Hospital mortality rates for the elective and emergency cases were 3.2% and 30.0%, respectively. One elective patient had a cerebral infarction (2.5%). LSA patency was successfully maintained in all 22 cases using a fenestrated stent graft. Conclusion The LSA plays an important role in brain circulation in some patients and so a preoperative LSA occlusion test is helpful when aortic stent-grafting is proposed. Fenestrated stent graft saved the LSA in more than 50% of the present cases. (Circ J 2008; 72: 449 -453)

Impact on outcomes by measuring tortuosity with reporting standards for thoracic endovascular aortic repair

“…6 TEVAR outcomes including occurrence and characteristics of endoleaks depend on the anatomic factors of the aortic disease. 7,8 Several reports describing heterogeneous pathologic processes have indicated that endoleaks are associated with anatomic factors, such as the diameter of the aneurysm, radius of the aortic curve, coverage of the left subclavian artery (LSCA), and tortuosity of the aorta, and procedural factors, such as the diameter, length, number, and completeness of apposition of the stent grafts. [9][10][11] Tortuosity of the aorta is reportedly related to the formation of endoleaks and bird-beak configuration; however, thus far, the methods used to calculate tortuosity have not been consistent with the reporting standards for TEVAR described by the Society for Vascular Surgery, 12,13 which aim to standardize findings regarding TEVAR.…”

Emergency TEVAR for Complicated Acute Type B Aortic Dissection

“…landing zone should be non-dissected aorta, generally, which is the aortic arch in cases of acute type B aortic dissection. Based on our study, there is a risk of complication around 5 % if LSA is simply covered by a stent graft (Kurimoto Y, et al, 2008a(Kurimoto Y, et al, , 2009). In addition of cerebral complication, a simple coverage of LSA possibly increases a risk of spinal cord ischemia as postoperative complication.…”

Management strategies for thoracic stent-graft repair of distal aortic arch lesions: is intentional subclavian artery occlusion a safe procedure?

“…Recently a new strategy to manage LSA has been reported with the development of a branched stent-graft designed to maintain the normal antegrade flow into the LSA [10-12, 24,25].…”