Transposition of Isolated Left Vertebral Artery in Hybrid Thoracic Endovascular Aortic Repair

Abstract

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery (ILVA) during complex thoracic aortic pathology treated with the hybrid thoracic endovascular aortic repair.Methods: This is a single-center, respective cohort study. Between June 2016 and June 2020, 13 patients (12 men; median age 60 years old, range 42–72 years old) who underwent hybrid procedures were identified with ILVA in our center. Demographics, imaging features, operation details, and follow-up in these patients were collected and analyzed.Results: In this study, all patients received the hybrid procedure, and the primary technical success rate was 100%. There were no in-hospital deaths. Complication occurred in two (15.4%) patients. One patient suffered from contrast-induced acute kidney injury (CI-AKI) and recovered before discharge. Another patient required reintervention for acute left-lower-limb ischemia, which was successfully treated using Fogarty catheter embolectomy. Immediate vagus/recurrent laryngeal never palsy, lymphocele, and chylothorax were not observed. The median duration of follow-up was 22 months (range, 13–29 months). No neurologic deficits, bypass occlusion, or ILVA occlusion or stenosis were observed during the follow-up. No aortic rupture, cerebrovascular accident, or spinal cord ischemia was observed during the follow-up period.Conclusions: Our limited experience reveals that hybrid procedures [thoracic endovascular aortic repair (TEVAR), ILVA transposition, and left common carotid artery-left subclavian artery (LCCA-LSA) bypass] are relatively safe, feasible, and durable for the treatment of thoracic aortic pathology with ILVA. However, further technique durability and larger studies with long-term follow-up periods are warranted.

Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair

“…ILVA can enter into basilar artery and terminate at posterior inferior cerebellar artery (PICA), which can supply the brainstem and cerebellum. It is necessary to manage the ILVA better to (9) held that all ILVA should be preserved if possible based on the fact that the prevalence of complete circle of Willis was 42% in western population and only 27% in Chinese population (8,22). And, Piffaretti and his colleagues held that reconstruction of a nondominant ILVA can help reduce the potential risk of spinal cord ischemia in patients with additional risk factors such as previous extensive aortic coverage (19).…”

“…At present, limited data on ILVA transposition during open surgery and hybrid procedure has been published showing satisfactory patency rate during short-term follow up period (9,18,19). But the interpretation of the results should be careful as the number of patients was small and the studies were singlecenter retrospective case series showing high risk of bias.…”

“…The presence of an ILVA has significant impact on the choice of aortic arch reconstruction techniques and cerebral protection methods ( 18 ). Current literature reported several options such as total open surgery ( 18 ), hybrid procedure ( 9 , 19 ) and parallel stents technique ( 20 ) to deal with aortic arch lesions and ILVAs. However, there was no consensus on the indication and strategy for ILVA reconstruction to date, as the relevant studies were scarce.…”

“…According to Ding and his colleague's experience ( 21 ), preservation of ILVA was favored, if ILVA was dominant, or if bilateral vertebral artery was symmetric with an incomplete circle of Willis. Differently, Yang and his colleague ( 9 ) held that all ILVA should be preserved if possible based on the fact that the prevalence of complete circle of Willis was 42% in western population and only 27% in Chinese population ( 8 , 22 ). And, Piffaretti and his colleagues held that reconstruction of a nondominant ILVA can help reduce the potential risk of spinal cord ischemia in patients with additional risk factors such as previous extensive aortic coverage ( 19 ).…”

“…The strategies of ILVA reconstruction was still uncertain in current guidelines. ILVA transposition has been used with favorable results ( 9 ). Total endovascular reconstruction has the advantages of improved safety and reduced invasiveness.…”