Left subclavian artery coverage during thoracic endovascular aortic repair: a single-center experience

This study was conducted to determine the results of left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR).

We retrospectively reviewed the results of 308 patients who underwent TEVAR from 1999 to 2007. The LSA was completely covered in 70 patients (53 men, 13 women), with a mean age of 67 years (range 41-89). Elective revascularization of the LSA was performed in 42 cases, consisting of transposition (n = 5), bypass and ligation (n = 3), or bypass and coil embolization (n = 34). Mean follow-up was 11 months (range, 1-48 months). The chi(2) test was used for statistical analysis.

Indications for treatment included aneurysm in 47, dissection in 16, transection in 4, pseudoaneurysm in 2, and right subclavian aneurysm in 1, with 47 elective and 23 emergency operations. Aortic coverage extended from the left common carotid artery (LCCA) to the distal arch (n = 29), middle thoracic aorta (n = 9), or celiac artery (n = 32). Operative success was 99%. The 30-day mortality was 4% (intraoperative myocardial infarction, 1; traumatic injuries, 1; visceral infarction, 1). No paraplegia developed. The stroke rate was 8.6%; no strokes were related to LSA coverage because there were no posterior strokes. Stroke rates between the revascularization (7%) and non-revascularization (11%) groups were not significantly different (P = .6). All but one patient fully recovered by 6 months. No left arm symptoms developed in patients with LSA revascularization. All bypasses remained patent throughout follow-up. One complication (2%) resulted in an asymptomatic persistently elevated left hemidiaphragm, likely related to phrenic nerve traction. Left upper extremity symptoms developed in five (18%) patients without LSA revascularization. Two required LSA revascularization, one of which was for acute limb-threatening ischemia. No permanent left upper extremity dysfunction or ischemia developed in any patient.

Zone 2 TEVAR with LSA coverage can be accomplished safely in both elective and emergency settings and with and without revascularization (with the exception of a patent LIMA-LAD bypass). Nevertheless, overall stroke rates are higher compared with all-zone TEVAR. Staged LSA revascularization and even urgent revascularization may be necessary but can be performed without long-term detriment to the left arm.