Occlusion of the left subclavian artery with stent grafts is safer with protective reconstruction.

BACKGROUND: Safe fixation of endovascular stent grafts in thoracic aortic disease often requires covering of the left subclavian artery (LSA) with the stent graft. It is controversial whether this occlusion can be done without additional risk of ischemic complications.

METHODS: In 102 patients treated with endovascular stent grafts, the LSA was covered. In a nonrandomized clinical practice, unprotected occlusion of the LSA was performed in 63 patients (61%), whereas 39 patients underwent extrathoracic subclavian to carotid artery revascularization before (n = 28) or concomitantly with (n = 11) the endovascular procedure.

RESULTS: Left cerebral ischemia occurred in 11% of the unprotected group and in 5% of the protected group. The difference was not statistically significant. The difference in spinal cord ischemia was insignificant owing to the low incidence in general, but the covered length of the aorta was significantly longer in the protected group. Arm ischemia after unprotected LSA occlusion occurred in 25%.

CONCLUSIONS: The interpretation of the results remains speculative because many factors contribute to left cerebral ischemia. However, in terms of overall complications, there is a significant difference in favor of the group protected by revascularization of the LSA either before or simultaneously with stent grafting. Arm ischemia is mostly mild and can be managed secondarily. Subclavian revascularization is associated with relatively low risk and should be considered in advance, at least when extended covering of the thoracic aorta is intended.