Management of the left subclavian artery during TEVAR – complications and mid-term follow-up

Abstract

Summary:Background: Numerous conditions that affect the boundary between the aortic arch and descending aorta are treated with thoracic endovascular aortic repair (TEVAR). In 40 % of cases, coverage of the left subclavian artery (LSA) cannot be prevented. Subsequently, neurological complications such as stroke or ischemia of the left upper extremity may develop. However, the actual risk of these complications is subject to considerable controversy. The optimal treatment approach, specifi cally the question whether primary revascularization of the LSA should be performed in all cases, is unclear. Patients and methods: The present retrospective study analyzed the short-and mid-term results of patients treated with TEVAR with complete coverage of the LSA. The postoperative protocol consisted of clinical and noninvasive examinations as well as morphological imaging. Survival, complication, and reintervention rates were recorded. Results: A total of 40 patients, undergoing TE-VAR with complete coverage of the LSA between January 2010 and December 2014 were analyzed retrospectively. The 30-day survival rate was 95 %, the survival one year after performed TEVAR was 67.5 %. The average follow-up was 1.5 years. After TEVAR procedure with complete coverage of the LSA, only one patient (2.5 %) developed critical ischemia of the left arm immediately after aortic stent implantation, requiring revascularization by transposition of the LSA. Anterior spinal artery syndrome occurred in another patient (2.5 %) immediately following TEVAR. During follow-up examinations, all patients showed a compensated arterial arm status. None of the patients developed new neurological defi cits during the follow-up period. Conclusions: The study shows that performing TEVAR without primary revascularization of the LSA was justifi able in our cohort. An important risk factor of developing cerebral ischemia seems to be insuffi cient collateralization through the circle of Willis.

Stroke, spinal cord ischemia and upper limb ischemia in patients undergoing TEVAR with coverage of the left subclavian artery: a case series study

“…While Youssef et al, concluded that covering the left subclavian artery without revascularization was justifiable in their cohort. The study included 40 patients who underwent TEVAR with complete coverage of the left subclavian during the procedure, only 2.5% developed critical upper limb ischemia that was in need of revascularization by transposition of the left subclavian artery, 2.5% developed anterior spinal artery syndrome, and none developed new neurological symptoms during follow up [44].…”

Hybrid treatment of aortic aneurism, type‐A dissection, and aortic valve stenosis

“…Graft-related complications after TEVAR occur in up to 20% of treated patients. 6 Retrograde type-A aortic dissection (RTAAD) following TEVAR and/or HAR is a well-known complication and can occur also several weeks after procedure. 7 In the last 10 year, we experienced only three cases of RTAAD, including the current one.…”

Experience with the Ankura Thoracic Stent Graft and In-situ Fenestration for the Left Subclavian Artery with the Fu-Through Needle - a Technical Overview and Comparison to Similar Endovascular Techniques

“…Thoracic endovascular aortic repair (TEVAR) is a minimally invasive and widely performed procedure used to treat thoracic aortic pathologies [1]. However, when the left subclavian artery (LSA) is involved in the pathology, a more complex surgical approach is required to guarantee the perfusion of the vertebral and brachial arteries [2,3]. In fact, coverage of the LSA has been proven to be associated with a higher of stroke, spinal cord ischemia, and arm ischemia [2].…”