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Increased Mortality Associated with Subclavian to Carotid Artery Transposition for Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair
Khanjan H. Nagarsheth, MD, MBA, RPVI, Viktor Dombrovskiy, MD, Saum Rahimi, MD.
Rutgers University - Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

Objective(s):
Left subclavian artery (LSA) coverage is an acceptable method for achieving an adequate proximal seal zone in patients undergoing thoracic endovascular aortic repair (TEVAR). The optimal method of LSA revascularization is still unknown, with only small series present in the literature. We sought to compare LSA revascularization techniques when performed for TEVAR.
Methods:
Patients with TEVAR and left subclavian artery coverage (CPT-4 code 33880) were selected in the Medicare Carrier and then MedPAR files 2007-2012 and outcomes in those with carotid-subclavian artery bypass (CSB) (35506, 35606) or subclavian-carotid artery transposition (SCT) (33889) were compared. Chi-square, multivariable logistic regression and t-test were used for analysis.
Results:
A total of 976 patients were evaluated: 702 with CSB and 274 with SCT; 64.2% patients were admitted electively. In bivariate analysis, there were no significant differences between these two groups in patients’ demographic characteristics and comorbid measures, rates of major postoperative complications. The greatest proportion of CSB (78.8%) was noted in major teaching hospitals; there were no significant difference in use of SCT and CSB between urban and rural hospitals. However, in multivariable analysis with adjustment by patient age, gender and race, comorbidities, postoperative complications, admission type and hospital characteristics patients with SCT were more likely to die in the hospital after TEVAR than those with CSB (OR [odds ratio]=2.4; 95%CI [confidence interval] 1.3-4.3). The other risk factors for hospital mortality were postoperative cardiac (OR=3.0; 95%CI 1.4-6.3) and respiratory complications (OR=3.4; 95%CI 1.9-6.2), sepsis (OR=4.3; 95%CI 1.7-10.6) and occlusion of cerebral arteries (OR=3.5; 95%CI 1.7-7.1). At the same time, patients with CSB compared to those with SCT had greater hospital length of stay (12.3±11.2 vs 10.2±9.3 days; P=0.0025). They also were more likely to be readmitted to the hospital during 30 days after index discharge (OR=1.6; 95%CI 1.1-2.4). Likelihood of 30-day readmission was significantly greater after non-elective surgery (OR=1.5; 95%CI 1.1-2.0).
Conclusions:
Subclavian-carotid artery transposition is associated with a greater than 2-fold increase in in-hospital mortality compared to CSB. Randomized controlled trials comparing CSB and SCT are needed to elucidate reasons for this increased mortality.


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