Chimney Grafting of Left Subclavian Artery for Neurovascular Rescue after TEVAR
Vahram Ornekian, MD, Joshua Dearing, MD, Edward Woo, MD, Steven Abramowitz, MD.
MedStar Washington Hospital Center, Washington, DC, USA.
Objectives: Presentation of a patient with Stanford B dissection necessitating emergent zone 2 endografting and resultant posterior cerebral ischemia. Chimney stenting was employed revascularizing the left subclavian artery as an alternative to carotid-subclavian bypass in a high risk patient. Methods: We present a 31-year-old Hispanic male who presented with complicated Type B dissection, dominant left vertebral artery and severe cardiomegaly. On presentation, he had evidence of left lower extremity ischemia consistent with Rutherford Category 2B. Imaging demonstrated coverage of his left subclavian artery would be required for treatment at the entry tear. His left vertebral artery was dominant measuring 7mm. Given the severity of his lower extremity ischemia, a decision was made to proceed with thoracic endovascular aortic repair (TEVAR) and lower extremity revascularization with staged left carotid-subclavian bypass. Intravascular ultrasonography (IVUS) confirmed a progression in the compression of the true aortic lumen. A 30mm stent was placed from just proximal to the left subclavian artery to the celiac artery. A cross femoral bypass was then performed. Femoral pulses were immediately restored bilaterally and IVUS confirmed expansion of the true lumen. Post-operatively, the patient developed symptoms of visual field loss as well as nystagmus. Magnetic resonance demonstrated cerebellar infarctions bilaterally consistent with low flow state to the posterior circulation. Additionally, he developed a worsening troponinemia and heart failure. Echocardiography demonstrated ventricular hypertrophy and compromised ejection fraction. He was a high risk for open surgical revascularization of his left subclavian artery and therefore an endovascular approach was chosen. The left brachial artery was exposed with local anesthesia and accessed with a 7fr sheath. Retrograde access was obtained of the ascending aorta and a 10mm x 38mm covered stent was placed just proximal to the aortic endograft into the left subclavian artery. Left vertebral artery flow was preserved. (Fig 1) Results: The patient immediately recovered his visual field deficits and had complete resolution of symptoms following subclavian artery stenting. He was discharged and follow up imaging demonstrated appropriate stent positioning. Conclusions: Subclavian artery chimney stenting is a viable rescue maneuver after emergent zone 2 TEVAR when carotid-subclavian bypass grafting presents prohibitive risk.
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