[Technologies for maintaining blood flow through the left subclavian artery during thoracic aortic replacement in the...

In modern clinical practice thoracic endovascular aortic repair is the dominant treatment method for patients with diseases of the descending thoracic aorta. In patients with a shorter proximal neck, there is a need to implant the stent graft in Ishimaru zone 2, which involves covering the left subclavian artery. In modern practice, both surgical and endovascular techniques for LSA preservation are available. Objective the aim of the study was to evaluate the efficacy and safety of endovascular aortic repair with coverage of the left subclavian artery using various preservation strategies.

А retrospective analysis of 126 patients who underwent endovascular aortic repair with coverage of the left subclavian artery. Two groups were identified: Group 1 - 83 (65.9%) patients who underwent endovascular left subclavian artery preservation, including: 'on-table' stent graft fenestration (Subgroup Ia) and in situ stent graft fenestration (Subgroup Ib); Group 2 - 43 (34.1%) patients who underwent carotid-subclavian bypass/transposition. A comparative analysis was conducted regarding technical success, left subclavian artery patency, complication and reintervention rates. For Subgroups Ia and Ib, a composite technical success endpoint was calculated, encompassing left subclavian artery patency, freedom from endoleaks, reinterventions, ischemic and vascular complications.

Intraoperative technical success was achieved in 100% of patients. In-hospital stroke and mortality rates were 1 (1.2%) and 1 (2.3%) in Groups 1 and 2, respectively (p=0.633). Vascular complications were significantly more frequent in Group 2: 14.0 vs 2.4% (p=0.019). Two cases of retrograde aortic dissection were recorded in Group 1. Reintervention rates in Groups I and II were 4.8% and 7%, respectively (p=0.616). In the long-term follow-up, left subclavian artery patency was 100% in both Groups. In Group II, there was 1 (2.3%) case of graft occlusion requiring reintervention to restore blood flow through the left subclavian artery. Composite technical success was 98% and 84.4% in Subgroups Ia and Ib, respectively (p=0.030). Subgroup Ib showed longer operative time (mean difference 44.7 minutes, 95% CI 23.9-65.4) and fluoroscopy time (mean difference 10.9 minutes, 95% CI 3.8-18).

Preservation of the left subclavian artery is advisable during endovascular aortic repair with proximal landing in Ishimaru zone 2. The choice of a specific preservation method is determined by the patient's clinical and anatomical characteristics. Endovascular techniques are a feasible and effective alternative to surgical methods of left subclavian artery preservation. The 'on-table' fenestration technique may offer advantages in reducing the overall rate of complications and reinterventions compared with in situ fenestration.