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Debranching versus Fenestrated Repair for Left Subclavian Artery Revascularisation during Thoracic Endovascular

Ahmed Azhar Ali1, Tilo Kölbel2, Luca Bertoglio3

  • 1Department of Vascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany; Department of Vascular Surgery, University Hospital, Mansoura University, Mansoura, Egypt. Electronic address: https://twitter.com/AhmedAzharMD.

European Journal of Vascular and Endovascular Surgery : the Official Journal of the European Society for Vascular Surgery
|December 11, 2025
PubMed

Insights

Fenestrated thoracic endovascular aortic repair (fTEVAR) offers a durable, low re-intervention alternative compared to carotid subclavian bypass with thoracic endovascular aortic repair (CSB-TEVAR). CSB-TEVAR is a practical option for urgent cases, but requires careful patient selection and follow-up due to higher re-intervention risks.

Area of Science:

  • Vascular Surgery
  • Endovascular Repair
  • Aortic Pathology Management

Background:

  • Left subclavian artery revascularization is crucial for thoracic endovascular aortic repair (TEVAR) when proximal landing zones 1 or 2 are required.
  • Open debranching techniques like carotid subclavian bypass (CSB) and transposition are alternatives to fenestrated TEVAR (fTEVAR).

Purpose of the Study:

  • To compare early and midterm outcomes of CSB-TEVAR versus fTEVAR for left subclavian artery revascularization.
  • To evaluate technical success, re-intervention rates, mortality, and complications in patients undergoing these procedures.

Main Methods:

  • Retrospective, international multicentre observational study (DEFENCE) from January 2019 to July 2023.
  • Propensity score matching (PSM) of 68 pairs to adjust for baseline differences between CSB-TEVAR and fTEVAR groups.
  • Analysis of technical success, 30-day outcomes, and long-term (12-36 months) re-intervention, mortality, and aortic-related complications.

Main Results:

  • In the matched cohort, CSB-TEVAR showed significantly higher overall and aortic-related re-intervention rates (14.7% vs. 3%, p = .031) compared to fTEVAR.
  • No significant differences in overall or aortic-related mortality were observed between the groups.
  • Cox regression identified CSB as an independent risk factor for increased re-interventions (HR 5.185, p = .035).

Conclusions:

  • Both CSB-TEVAR and fTEVAR achieve high technical success and similar long-term mortality.
  • fTEVAR is a durable option with lower re-intervention rates.
  • CSB-TEVAR is a viable option for urgent situations but necessitates individualized selection and close monitoring due to higher morbidity and re-intervention risks.
Abstract

Keywords:
Aortic pathologyCarotid subclavian bypassFenestrated thoracic endovascular aortic repairLeft subclavian arteryPropensity score matchingThoracic endovascular aortic repair

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