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Title: Management and Outcome of Partial Subclavian Artery Coverage in Patients undergoing TEVAR
Objective: It is generally believed that it is mandatory to preserve flow into the left subclavian artery in patients who undergo thoracic endovascular aortic repair for dissection. This dogma is supported by the fact that left upper extremity receives the majority of its blood supply from the thoracic aorta. Others have suggested that it is safe and effective to cover the left subclavian artery; alternatively snorkeling the left subclavian has also been described. In an attempt to identify a sub-group of patients in whom coverage of the left subclavian could be averted, we critically evaluated a cohort of patients who had partial coverage of their left subclavian artery.
Materials and Methods: Four thoracic endovascular repairs were performed for dissection in our institution during a 3 month period from January 2015 until March 2015. Patients were deemed eligible for endovascular repair after they had failed conservative medical management. There were 4 males and no female patients ranging in age from 52-91 years (mean 66.5 years ± 16.9). One patient had thoracic aorta repair for acute dissection with ischemia to the leg, one patient had treatment for dissection with rupture, and two patient had repair for dissection after failed medical therapy. Three patients underwent repair with the Gore Tag device and one patient with the Medtronic Talent.
Results Technical success was achieved in 75% of patients, with 100% of cases done percutaneously. Within 30 days there were no deaths, no aortic ruptures, no myocardial
infarctions, or conversions to open repair. One patient experienced procedure-related perioperative stroke. Freedom from reintervention in our group was 75%, one patient required axillary –axillary bypass for inadvertent coverage of the left subclavian artery. There was no spinal cord ischemia.
Conclusion: Currently, the optimal approach to the thoracic aorta is not supported by strong evidence. In spite of this, partial coverage of the left subclavian artery in patients who have less than 2 cm seal zone appears to be effective. However due to our small sample size, heterogeneous settings, limited follow-up and lack of a comparison cohort, further investigation is necessary.