Patency of Extra-anatomic Left Subclavian Arterial Bypass in Aortic Arch Surgery

Background: Left subclavian artery (LSA) bypass may be indicated in (sub-)total aortic arch surgery. Guidelines recommend revascularization instead of overstenting the LSA. The LSA may represent a technical challenge to the surgeon in a hostile anatomy.

Methods: Consecutive aortic repair patients (n = 342) over a 4,5 years (01/2019 - 06/2023) period were reviewed on an institutional basis. LSA perfusion was studied clinically and with CT.

Results: In a subgroup of 33/342 (10%) patients, (sub-)total arch replacement to Ishimaru zones 2 and 3 was performed using prostheses with a perfusion side-arm for lower body perfusion in circulatory hypothermic arrest. The principal diagnosis was type A dissection (29/33, 88%). Surgeries consisted concomitantly in 6/33 (18%) re-do surgeries, 12/33 (36%) full aortic root repairs and 4/33 (12%) other valve corrections. The perfusion side-arm was used for extra-anatomic (EA) LSA bypass via a transpleural route in 19/33 (58%) frozen ET procedures. In 14/33 (42%), the LSA was either anatomically anastomosed (frozen ET, 9/33, 27%) or spared (conventional branched prosthesis to zone 2, 5/33, 15%). In EA LSA bypasses mortality was higher because of neurological and other malperfusion disease.

All survivors of zone 2 and 3 repairs (n = 24, 73%) showed no clinical left arm ischemia and patent angio-CT (mean follow-up time 12 months). In 1/13 (8%), functional complaints (vertigo on exertion) were found.

EA LSA Bypass	No	Yes	Total
Pat. (no.)	14 (42%)	19 (58%)	33 (100%)
Age (mean ± SD)	60 ± 12	62 ± 11	61 ± 11
Sex (m/f)	11/3	16/3	27/6
Aneurysm (% of column)	1 (14%)	3 (16%)	4 (12%)
Type A dissection (% of column)	13 (93%)	16 (84%)	29 (88%)
Pre-/postoperative neurol.	1 (25%)/4 (57%)	3 (75%)/3 (43%)	4 (100%)/7 (100%)
Organ ischemia/ multi organ failure*	2 (25%)	6 (75%)	8 (100
In-hospital mortality**	3 (33%)	6 (67%)	9 (100%)

Conclusion: EA LSA bypass in aortic arch repair is a valuable solution for LSA revascularization in total arch repair.

Publikationsverlauf

Artikel online veröffentlicht:
13. Februar 2024