Key result
Maintaining left subclavian artery patency during TEVAR for chronic type B aortic dissection did not significantly affect rates of cerebrovascular accident (P=0.16), spinal cord ischemia, or death.
Why the study?
Left subclavian artery (LSA) revascularization during TEVAR remains controversial, and LSA coverage without revascularization can cause stroke and death.
Does maintaining LSA patency or revascularization reduce perioperative morbidity or death compared to LSA occlusion in patients undergoing TEVAR for chronic type B aortic dissection?
Cohort (n=208)
Yes
Does maintaining LSA patency or revascularization reduce perioperative morbidity or death compared to LSA occlusion in patients undergoing TEVAR for chronic type B aortic dissection?
p-value: p=0.16 for CVA, 1.00 for SCI/death
In patients undergoing TEVAR for chronic type B aortic dissection, maintaining LSA patency or performing revascularization did not improve perioperative morbidity or mortality compared to LSA occlusion.
Supports selective left subclavian management during TEVAR; leaves open need for randomized trials to guide revascularization.
Objectives: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. Methods: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. Results: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( P = .16), spinal cord ischemia ( P = 1.00), or death ( P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). Conclusions: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.
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Conway et al. (2020) conducted a cohort in chronic type B aortic dissection (cTBD) (n=208). Maintaining LSA patency (revascularization or maintained patency) vs. LSA occlusion without revascularization was evaluated on cerebrovascular accident, spinal cord ischemia, or death (p=0.16 for CVA, 1.00 for SCI/death). Maintaining left subclavian artery patency during TEVAR for chronic type B aortic dissection did not significantly affect rates of cerebrovascular accident (P=0.16), spinal cord ischemia, or death.
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