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Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma
Anna Noel Romagnoli1, Jeanette Paterson, Anahita Dua
1From the Division of Endovascular Trauma, R Adams Cowley Shock Trauma Center (A.N.R.), Baltimore; Division of Trauma and Acute Care Surgery Walter Reed National Military Medical Center (A.N.R., J.P.), Bethesda, Maryland; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital (A.D.), Boston, Massachusetts; Division of Vascular Surgery, Denver Health Medical Center, Denver, Colorado (D.K.); Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (N.S., C.M.), Houston, Texas; Division of Vascular Surgery, University of Washington Medical Center (B.S.), Seattle, Washington; Division of Vascular Surgery, Cedars Sinai Medical Center (A.A.), Los Angeles, California; and Division of Vascular Surgery, Dell University School of Medicine, University of Texas (J.D.B.), Austin, Texas.
Background:
Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C.
Methods:
The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization.
Results:
Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients ( p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U ( p = 0.04, p = 0.01, p = 0.001).
Conclusion:
While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary.
Level Of Evidence:
Therapeutic/Care Management; Level III.
