Back to Annual Meeting Posters

Introduction:
Coverage of the subclavian artery (SCA) during thoracic endovascular aortic repair (TEVAR) can result in compromised brain and extremity blood flow. Revascularization is recommended using a carotid-subclavian artery (C-SCA) bypass or transposition. With a C-SCA bypass, the proximal SCA can cause a type 2 endoleak if not surgically ligated or occluded with endovascular (EV) techniques: Amplatzer plugs, coils, or iliac occlusion plugs. We have noted posterior strokes associated with the Amplatzer plug II, and reviewed our experience with C-SCA bypass during TEVAR, focusing on the management of the proximal SCA and sequencing of TEVAR in respect to the proximal SCA treatment.
Methods:
This is a single center, retrospective review of all patients that had C-SCA bypass and TEVAR. Patients were divided into two groups: Group 1 all had an Amplatzer plug used to occlude the proximal SCA after C-SCA bypass and prior to TEVAR. Group 2 included all others that had either: no ligation, coil embolization, or iliac plug occlusion of the proximal SCA, occurring before or after TEVAR.
Results:
Fifteen patients were identified, average age 68 + 11. The indication for surgery was aortic arch or descending thoracic aortic aneurysm in all but one patient with coarctation. All C-SCA bypasses were performed prior to TEVAR. Posterior circulation strokes occurred in 2 patients in group 1 (n=8) and none in group 2 (n=7). In group 2, the proximal SCA was either not treated (n=2), managed prior to TEVAR [with a Medtronic iliac plug (n=1) or surgical ligation (n=1)], or managed after TEVAR [with surgical ligation (n=1), coil embolization (n=1) or Cook iliac occlusion plug (n=1)]. There were no type 2 endoleaks from the SCA in either group. Five patients (three in group 1 and two in group 2) also underwent complete arch debranching, none of which had strokes.
Conclusion:
Two posterior circulation strokes occurred with the Amplatzer plug when placed prior to TEVAR. We suggest that as thrombus forms over the plug, parallel antegrade flow in the SCA can result in emboli to the vertebral artery distribution. We recommend that TEVAR be completed prior to Amplatzer plug placement, an iliac occlusion plug be used, or the patient maintained on full anticoagulation until the thoracic endograft is deployed covering the SCA origin.