Sandwich Periscope Stenting Technique for Left Subclavian Artery Revascularization during Zone 2 Thoracic Endovascular Aortic Repair
Cali E. Johnson, MD, EdD, Louis Zhang, MD, Gregory A. Magee, MD, MSc, Sung W. Ham, MD, Kenneth R. Ziegler, MD, Fred A. Weaver, MD, MMM, Fernando Fleischman, MD, Michael Bowdish, MD, Sukgu M. Han, MD, MSc.
University of Southern California, Los Angeles, CA, USA.
OBJECTIVES: Revascularization of the left subclavian artery (LSCA) during zone 2 thoracic endovascular aortic repair (TEVAR) maintains collateral circulation to decrease ischemic complications including stroke, spinal cord ischemia, and upper extremity ischemia. Endovascular revascularization by LSCA stenting avoids manipulation of the left carotid artery. Sandwich configuration of the periscope LSCA stent minimizes gutter leaks by creating a long overlap, while preserving both left arm access and branchless distal overlap zone for future endovascular thoracoabdominal aortic repair. We present our early experience with LSCA sandwich periscope technique during initial zone 2 TEVAR.
METHODS: A single institution, retrospective review was performed on patients who underwent LSCA sandwich periscope TEVAR. The presenting aortic pathology and perioperative complications were recorded. Intraoperative angiography, and postoperative CT images were reviewed for incidence of endoleaks. Branch patency was determined based upon last available CT scans.
RESULTS: Sixteen patients underwent LSCA sandwich periscope TEVAR at our institution from January 2017 to August 2018. Indications for TEVAR were 13 type B dissections, two thoracoabdominal aneurysms, one pseudoaneurysm. Perioperative complications were seen in two patients, one with stent induced new entry tear causing distal ischemia, and one with transient ischemic attacks. There was no postoperative spinal cord ischemia or clinically significant left arm ischemia. At median follow-up of one month (range 0-12), primary patency of the LSCA branch was 100%. There were four gutter leaks on completion angiography during the initial TEVAR. Three resolved without intervention by one month and none required unplanned reintervention for persistent gutter leaks. One patient had a fatal rupture of an extent II thoracoabdominal aortic aneurysm one month after undergoing LSCA sandwich periscope TEVAR as the first of a planned two-stage repair. The LSCA periscope was accessed in one patient for brachiofemoral access and branch treatment during a subsequent distal intervention. Access is planned for two patients awaiting fenestrated endovascular repair of the thoracoabdominal aorta.
CONCLUSIONS: LSCA sandwich periscope stenting provides a safe means of LSCA revascularization during zone 2 TEVAR with good short term outcomes. This technique may be a useful adjunct in facilitating staged branched, fenestrated endovascular repair of thoracoabdominal aortic pathologies. 
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