Coverage of the Left Subclavian Artery Without Revascularization can be Performed Safely in Patients Undergoing TEVAR for Chronic Type B Aortic Dissection
Allan M. Conway, MD, Khalil Qato, MD, Laurie Mondry, BSN, Gary Giangola, MD, Alfio Carroccio, MD.
Lenox Hill Hospital, New York, NY, USA.
Objective(s): Left subclavian artery revascularization in patients undergoing TEVAR remains controversial. LSA coverage without revascularization can cause arm ischemia, stroke and death. SVS Practice Guidelines recommend LSA revascularization in elective TEVAR for aneurysms involving coverage of the LSA. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative database we reviewed outcomes of LSA revascularization in TEVAR for cTBD.
Methods: The VQI registry identified 5,683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD with aneurysm. We analyzed TEVAR outcomes in cTBD as per the SVS reporting standards, and its association with revascularization of the LSA.
Results: Of 208 patients, 150 (72.1%) were male with a mean age of 63.2 years (SDą12.5). Average aneurysm diameter was 5.7cm (SDą1.2). Data on the LSA patency was available in 131 (63.0%) patients. Twenty-five (19.1%) patients had occlusion of the LSA without revascularization while 106 (80.9%) maintained patency or had revascularization. Management strategies are summarized in Table 1. Successful device delivery occurred in all 131 (100%) patients. Following TEVAR, the LSA was patent in 98 (74.8%) patients. Forty-eight patients underwent LSA revascularization, and the patency rate was 83.3%, with seven bypasses and one chimney occluded. Maintaining the patency of the LSA did not affect the rate of arm ischemia (p=0.19), cerebrovascular accident (p=0.16), spinal cord ischemia (p=1.00) or death (p=1.00). This was also non-significant when analyzing the subgroup of 98 elective cases. There was no difference in rates of endoleak (p=0.14). Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6minutes vs.163.7minutes, p=0.04). Follow-up was available for 41 patients at a mean time of 250 days (SDą204). Mean change in sac diameter was -0.4cm (SDą1.5). Occlusion of the LSA did not affect the rate of sac shrinkage (-0.3cm vs.-0.5cm, p=0.73).
Conclusions: Maintaining LSA patency during TEVAR for cTBD offers no advantage in terms of perioperative morbidity, mortality, endoleak or changes in sac diameter. LSA occlusion can be performed safely. Revascularization should be reserved for those who have anatomy that compromises perfusion to critical organs.
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