Management of left subclavian artery in endovascular stent-grafting for distal aortic arch disease

Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair

OBJECTIVE

Coverage of the left subclavian artery (LSA) is often required to achieve complete proximal sealing during thoracic endovascular aortic repair. However, whether LSA revascularization should be performed remains controversial.

METHODS

MEDLINE, Embase, and Cochrane databases were systematically searched to identify all the relevant studies. A random-effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR).

RESULTS

There were 32 studies included for qualitative analysis and 31 studies for quantitative analysis. We found that patients who underwent LSA revascularization had a significantly decreased risk of spinal cord ischemia (OR, 0.62; 95% confidence interval [CI], 0.41-0.92; P = .02; I² = 0%), cerebrovascular accident (OR, 0.63; 95% CI, 0.42-0.95; P = .03; I² = 22%), and left upper extremity ischemia (OR, 0.18; 95% CI, 0.09-0.36; P < .00001; I² = 0%). However, no significant differences were found in the risk of paraplegia (OR, 0.91; 95% CI, 0.55-1.51; P = .71; I² = 0%) and 30-day mortality (OR, 0.89; 95% CI, 0.59-1.36; P = .60; I² = 21%) between the groups of patients with and without LSA revascularization.

CONCLUSIONS

Revascularization of the LSA is associated with decreased risks of cerebrovascular accident, spinal cord ischemia, and left upper limb ischemia in thoracic endovascular aortic repair with LSA coverage at the cost of higher local complications, such as possible vocal cord paresis.

Fenestrated stent-graft facilitates emergency endovascular therapy for blunt aortic injury

BACKGROUND

Endovascular stent-grafting with intentional coverage of the left subclavian artery may be used to treat aortic isthmus injury, but this procedure may have serious neurologic sequelae and may not provide an adequate proximal landing zone. In 2005, in an effort to mitigate these problems, we began to use fenestrated stent-grafts for emergency repair of blunt aortic injury (BAI).

METHODS

Between 2005 and 2007, all patients in our practice with a BAI with mediastinal hematoma (except young patients without an associated critical injury) were treated with immediate endovascular stent-grafting, if anatomically possible. A fenestrated stent-graft was placed from the aortic arch, if the BAI was less than 20-mm distal of the left subclavian artery. The records of the 13 patients in the series were reviewed retrospectively.

RESULTS

The BAI treatment was successful in all 13 patients. Eight patients (61.5%) were given a fenestrated stent-graft, placed distal to either the ascending aorta (n = 2), brachio-cephalic artery (n = 4), or left common carotid artery (n = 2), without concomitant bypass grafting or transposition of the head vessels. Two patients died of an associated critical brain injury (hospital mortality rate, 15.4%). There were no perioperative complications related to stent-graft usage and no unintentional occlusions of the head vessels by a fenestrated device. One patient underwent open repair of a newly developed type Ia endoleak 7 months after placement of a nonfenestrated stent-graft.

CONCLUSION

Fenestrated stent-grafts can be used to treat BAI, without any concomitant procedures to provide an adequate proximal landing zone.