Outcomes of the endovascular management of aortic arch aneurysm: implications for management of the left subclavian artery

Peter J Holt, Chris Johnson, Robert J Hinchliffe, Robert Morgan, Marjan Jahingiri, Ian M Loftus, Matt M Thompson
Journal of Vascular Surgery 2010, 51 (6): 1329-38

BACKGROUND: This study was conducted to define the outcomes of treating aortic aneurysms involving the arch vessels with a hybrid approach using extra-anatomic reconstruction and endovascular repair with nonfenestrated stents.

METHODS: A single-center review was done of arch aneurysm endovascular repairs during an 8-year period. Data were collected for patient demographics and aneurysm pathology. Any revascularization procedures performed were analyzed to detect differences between groups and through fitting a logistic regression model. The outcome measures were postoperative death, stroke, and paraplegia.

RESULTS: Between 2001 and 2009, 78 patients (65% men; mean age, 65 years) underwent endovascular repair of aortic arch aneurysms. Coverage of the left subclavian artery (LSA) was necessary in all patients to access an adequate proximal landing zone. An Ishimaru zone 0 proximal landing zone was present in 9 patients, 17 had zone 1, and 52 had zone 2. Fifty patients (64%) underwent elective endografting with an in-hospital mortality rate of 4%, and 28 patients (36%) underwent emergency procedures with a mortality rate of 14.3%. The LSA was revascularized in 31 elective (62%) and 4 emergency patients (14%). LSA revascularization was associated with significantly better outcomes for the combined measure of death, stroke, and paraplegia (odds ratio [OR], 15.6; 95% confidence interval [CI], 1.83-142; P = .012). Patients with an atherosclerotic aneurysm had worse outcomes than those with aortic dissection (OR, 5.52; 95% CI 1.26-24.4; P = .024), with dissections having preponderance toward emergency procedures (OR, 2.92; 95% CI, 1.12-7.58; P = .035).

CONCLUSION: Aneurysms involving the aortic arch vessels can be effectively treated by staged endovascular-surgical hybrid procedures with good outcomes that can be further improved through prior revascularization of the LSA.

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