Optimal management of isolated left vertebral artery in total arch replacement with frozen elephant trunk for aortic dissection

Background The presence of an isolated left vertebral artery (ILVA) in patients with aortic dissection (AD) is a rare and challenging condition. This study aims to determine the optimal management of ILVA in patients with AD undergoing total arch replacement with frozen elephant trunk (TAR with FET). Methods This retrospective study enrolled 94 patients with ILVA and AD who underwent TAR with FET. Patients were divided into three groups: 18 patients underwent ligation of ILVA, 52 underwent ILVA- left subclavian artery (LSCA) transposition, and 24 underwent ILVA- left commn carotid artery (LCCA) transposition. Results Vertebral artery dominance was left-dominant in 10.6%, symmetric in 33.0%, and right-dominant in 56.4% of patients. Notably, patients who underwent ligation of ILVA had either symmetric or right-dominant vertebral arteries, with no left-dominant cases. No strokes were observed. Paraplegia/paraparesis, mechanical ventilation time, and long-term survival were comparable among the three groups. Follow-up computed tomographic angiography (CTA) confirmed patency of the left vertebral artery in all patients who underwent ILVA transposition. Conclusions Ligation of ILVA, ILVA-LSCA transposition, and ILVA-LCCA transposition are all feasible and safe strategies for managing ILVA in patients with AD undergoing TAR with FET. However, ligation of ILVA is not recommended for patients with left-dominant vertebral arteries.