Thoracic endovascular aortic repair with left subclavian artery coverage without prophylactic revascularisation-early and midterm results

J Wojciechowski, L Znaniecki, K Bury, J Rogowski
Langenbeck's Archives of Surgery 2014, 399 (5): 619-27

BACKGROUND: The management of the left subclavian artery when coverage is necessary during thoracic aorta endografting remains a matter of debate.

MATERIALS AND METHODS: A retrospective analysis of a single-centre experience with thoracic endovascular aorta repair (TEVAR) was performed. Between April 2004 and October 2012, 125 cases of TEVAR were performed. The analysis focused on patients who required coverage of the left subclavian artery (LSA). We analysed mortality and morbidity with special attention to the rates of cerebrovascular accidents (CVAs) and spinal cord ischaemia (SCI) in the early and midterm.

RESULTS: Of the 125 patients, 53 (42 %, group A) required an intentional coverage of the LSA to obtain an adequate proximal seal for the endograft; the remaining patients constituted group B. None of the patients in group A had protective LSA revascularisation prior to TEVAR. The primary technical success rate was 79.2 vs. 90.3 % (group A vs. group B, p = 0.08), and the primary clinical success rate was 77.4 vs. 82 % (group A vs. group B, p = 0.53). The 30-day mortality rate was 11.3 vs. 11.1 % (group A vs. group B, p = 0.97). The 30-day morbidity was 7.5 vs. 13.9 % (group A vs. group B, p = 0.4). CVA occurred in 1.9 % of group A patients, compared to 1.4 % of patients from group B (p = 0.82). The SCI incidence rate was 0 vs. 1.4 % (p = 0.39). The mean follow-up of group A was 24.1 months (range 2-64.6 months, SD = 19). Additionally, the 1-year estimated survival was 85.5 %, and the 3-year estimated survival was 78 %. There were no midterm CVAs; one event of SCI occurred in the seventh post-operative month in group A.

CONCLUSION: Our analysis, although retrospective and based on one institution experience, shows a realistic population of TEVAR patients. We prove that TEVAR with coverage of LSA origin can be accomplished with minimal neurological morbidity in this patient population. The study shows that LSA revascularisation is not mandatory before endograft deployment, especially in emergency settings. We also prove that although zone 2 TEVAR extends the proximal landing zone, it does not prevent type IA endoleaks from appearing. A multicentre randomised control trial with higher number of patients is necessary for proper, robust conclusion to be established.

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