Management of the left subclavian artery during zone II thoracic endovascular aneurysm repair: a systematic review and network meta-analysis

The aim of this study was to compare interventions for left subclavian artery (LSA) revascularization during zone II thoracic endovascular aortic repair (TEVAR). A systematic review was conducted per PRISMA 2020 and PRISMA-NMA2015 guidelines, focusing on interventions for LSA management during TEVAR. Primary endpoints included perioperative ipsilateral stroke, LSA patency, and overall LSA patency. Twenty-four studies (N.=2893) compared carotid-subclavian bypass (CSB), subclavian-to-carotid transposition (SCT), branched endografts, fenestration, chimney technique, and LSA coverage. Branched endografts significantly reduced the risk of perioperative ipsilateral stroke compared to SCT (RR 0.02) and CSB (RR 0.01). CSB and SCT showed better overall LSA patency, but branched endografts demonstrated superior perioperative LSA patency. The chimney technique had the highest likelihood of perioperative spinal cord ischemia, while fenestration was least likely to result in postoperative complications. Both endovascular and open procedures are viable, but branched and fenestrated endografts should be prioritized due to superior safety and efficacy.