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Endograft Coverage of the Left Subclavian Artery during repair of Traumatic Thoracic Aoritic Injury may be associated with Significant Long Term Morbidity
Michael Madigan, MD, Elizabeth Genovese, MD, Mikhail Attaar, Louis Alarcon, MD, Michael Singh, MD, Michel Makaroun, MD, Eric Hager.
UPMC, Pittsburgh, PA, USA.
Objective(s): Coverage of the left subclavian artery during thoracic endovascular aortic repair (TEVAR) has reportedly minimal long-term sequelae. As it is being used frequently in traumatic aortic transection, we hypothesized that trauma patients with LSCA coverage may often require secondary interventions due to ischemic complications.
Methods: We conducted a single institution, retrospective chart review of 82 patients who underwent TEVAR for blunt aortic transection (2004-2014). Patient demographics, co-morbidities, concomitant injuries, details of the intervention and thoracic aortic injury grade were collected. The outcomes included were immediate and long-term mortality rates, stroke, endoleak, device migration, lesion regression, open conversion, and reintervention rates secondary to morbidity associated with LSCA coverage. Statistical analysis included chi-squared test, Fisher’s exact test, t-test, and Kaplan Meier analysis.
Results: Eighty two patients were treated with TEVAR with a technical success rate of 100% and mean follow up of 2.3 ± 2.4 years. Fifty eight patients had TEVAR without LSCA coverage while 23 patients (28.0%) required either partial or complete coverage. The overall 30 day mortality rate was 7.3% (n=6), mostly due to associated injuries. Mortality was similar between those with and without LSCA coverage (6.9 v 8.7%, P=1.0). Patients with LSCA coverage had significantly more hemodynamic instability on presentation than those who did not require LSCA coverage (43% vs 19%; P=.023). Adverse events and reinterventions associated with LSCA included one patient who died of concomitant trauma and one who died from an immediate, massive posterior stroke resultant from LSCA coverage. One patient was immediately revascularized due to previous LIMA-LAD bypass and one revascularized due to immediate arm ischemia. Of the remaining 18 who were discharged without immediate revascularization, 5 required delayed revascularization for exertional arm pain or ischemia (table 1). One-year survival rates were similar between groups (90.9% vs, 91.3%, P=.976).
Conclusions: In this study, the LSCA required coverage in
approximately a quarter of patients during TEVAR for traumatic aortic injury to achieve an adequate proximal seal zone. This was associated with a significant incidence of late arm symptoms requiring revascularization suggesting that it is not as benign a procedure as initially thought.
Morbidity Related to LSCA Coverage During TEVAR
|Patient Number||Age||Time to Intervention (days)||Intervention||Morbidity|
|1||69||0||None||Death due to posterior stroke|
|2||79||0||Left carotid-subclavian bypass||Prophylactic revascularization for prior LIMA-LAD|
|3||71||0||Lt. subclavian stent||Immediate arm ischemia|
|4||41||865||Graft explant and open bypass||Arm claudication|
|5||22||693||Left subclavian transposition||Subclavian steal syndrome|
|6||30||164||Left subclavian transposition||Subclavian steal syndrome|
|7||18||835||Left carotid-subclavian bypass||Subclavian steal syndrome|
|8||37||672||Left subclavian stent||Arm claudication|
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