Management of Urgent Endovascular Aortic Repair Requiring Coverage of the Left Subclavian Artery

Background: Thoracic endovascular aortic repair (TEVAR) of acute aortic syndromes (AAS) involving the distal aortic arch often requires coverage of the left subclavian artery (LSA). We evaluate the optimal management to reduce the risk of ischemic complications for this therapy.

Method: Fifty-two patients with AAS underwent urgent TEVAR (03/2017–05/2021) requiring proximal landing in the distal aortic arch. Decision for partial or complete LSA ostial endograft coverage, with or without additional bypassing, was made depending on the aortic pathology and individual vascular anatomy. Analysis included patency of carotid and vertebral arteries, the basilar artery, and the circle of Willis. 35% underwent complete LSA coverage (complete-LSA group) and 17% partial LSA coverage (partial-LSA group), whereas in 48% the LSA ostium was reached only by the bare springs of the endograft (control group). 22% of the complete-LSA group with left vertebral artery advantage underwent LSA bypass before TEVAR, whereas 11% with anticipated extended TEVAR underwent CSF drainage. Endpoints were 30-day and 1-year mortality, stroke, spinal cord ischemia (SCI), and arm malperfusion.

Results: A successful aortic repair was achieved in 96%. The effective stent length was 171 ± 34 (complete-LSA group) versus 151 ± 22 (partial-LSA group) versus 181 ± 52 mm (control group), covering 6 ± 2 versus 5 ± 1 versus 7 ± 2 intercostal arteries. Proximal endoleak rates were 11% (complete-LSA group) versus 11% (partial-LSA group) versus 4% (control group). The 30-day mortality (0% vs. 0% vs. 8%), stroke (0% vs. 0% vs. 4%) and SCI rates (0% vs. 0% vs. 4%) did not differ significantly. One patient presented with arm malperfusion and underwent LSA bypass post-TEVAR. After 1 year, aortic reinterventions were needed in 6% (complete-LS group) versus 22% (partial-LSA group) versus 13% (control group). The 1-year mortality (0% vs. 0% vs. 8%), stroke (6% vs. 0% vs. 4%), and SCI (0% vs. 0% vs. 4%) did not differ between groups.

Conclusion: For elective TEVAR covering the distal aortic arch, the LSA should be revascularized. In an urgent situation, a decision pathway based on the individual vascular anatomy may provide similar results. In patients with total LSA coverage, a stent length of ≥200 mm and/or a coverage of ≥7 intercostal arteries should be avoided. In emergency cases, a hypo- or malperfusion of the left arm may be treated subsequently.

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Artikel online veröffentlicht:
28. Januar 2023