Prophylactic Subclavian Artery Revascularization is Protective Against Lower Extremity Neurologic Deficits with TEVAR
Hunter M. Ray, MD, Paul G. Haddad, BS, Charles C. Miller, PhD, Harleen K. Sandhu, MD, MPH, Naveed U. Saqib, MD, Ali Azizzadeh, MD, Hazim J. Safi, MD, Kristofer M. Charlton-Ouw, MD.
The University of Texas Health Science Center at Houston (UT Health), McGovern Medical School, Houston, TX, USA.
OBJECTIVES:
Subclavian artery revascularization (SAR) was initially performed for occlusive disease but is now often performed to obtain proximal landing zone for thoracic endovascular aortic repair (TEVAR) and to reduce stroke and lower extremity neurologic deficit (LEND). The effect of SAR in reversing LEND after TEVAR is unclear.
METHODS:
Patients who underwent SAR from 2001-2018 were reviewed and grouped by indication: (A) without TEVAR; (B) before TEVAR; and (C) after TEVAR. A composite complication outcome was defined as LEND, cerebrovascular accident (CVA), myocardial infarction (MI), and/or in-hospital mortality. Analysis was by stratified Kaplan-Meier and Cox regression analysis using SAS v9.4 (SAS Institute, Cary, NC).
RESULTS:
We performed 76 SAR with mean age of 63.1±13.8 years and with 29.9% female. Group A had 9 cases with zero composite complication. Group B had 51 cases with no LEND. Group C had 16 cases with 37.5% (6/16) LEND which was higher than groups A or B (p<0.01). Prophylactic SAR is superior to delayed revascularization with 0% permanent LEND in Group B versus 12.5% in Group C (p=0.02). There was no significant difference in CVA between groups A, B and C with 0%, 7.84%, and 6.25%, respectively (p=0.68). MI was rare with 1 case (1.32%) in the cohort. In-hospital mortality was 2.63% with no difference between groups (p=0.56). No difference was noted in overall complication rates between groups (p=0.35). Sex (p=0.59), diabetes (p<0.07) and aortic dissection (p<0.72) failed to predict complication. There was also no difference in complications between bypass compared with transposition.
CONCLUSIONS:
Outcomes after SAR are acceptable but with increased CVA noted in TEVAR cases. Prompt SAR in patients with LEND after TEVAR appears effective in restoring neurologic function in many patients. Outcomes are superior after prophylactic SAR when subclavian coverage is needed during TEVAR.
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