Comparison Of Surgical Debranching Versus Branched Endografts In Zone 2 TEVAR
William P. Shutze, Sr., MD1, Ronald Baxter, MD1, Cara Gable2, Katherine Harrington, MD1, Justin Schaffer, MD1, David Moore, MD1, William Brinkman, MD1, Dennis Gable, MD1, Michael Dimaio, MD1.
1The Heart Hospital Baylor Plano, Plano, TX, USA, 2Texas Vascular Associates, Plano, TX, USA.
IntroductionIshimaru zone 2 thoracic endovascular aortic repair (TEVAR) has required intentional left subclavian artery coverage or surgical revascularization of the left subclavian artery (LSA) followed by TEVAR (SR-TEVAR). The development of a made thoracic endograft with a side branch has made endovascular revascularization of the LSA with concomitant TEVAR (TBE) possible without requiring fenestration or parallel endografting. We hypothesized that there would be significant differences s between these two LSA revascularization methods during zone 2 TEVAR.
MethodsWe performed a retrospective review of all patients undergoing a Zone 2 proximal landing zone TEVAR from 2015 through 2020 at our institution while we were prospectively enrolling patients in an IRB approved vendor sponsored study of TEVAR with a branched device designed for LSA revascularization. Patients during the study period who received intentional LSA coverage without revascularization were excluded. Pre-operative, operative, and post-operative variables were compared in patients undergoing either SR-TEVAR or TBE using two-sample t tests for continuous variables and the χ2 or Fischer exact test for categorical variables.
ResultsDuring the study we identified 75 patients undergoing a zone 2 TEVAR and excluded 20 without LSA revascularization leaving 31 in the TBE group and 24 in the SR-TEVAR Group. Debranching procedures were subclavian artery bypass (20) or transposition (11). All TEVAR were successful and without peri-operative stroke. Patient demographics and comorbidities are detailed in Table 1 with the only difference being a lower hemoglobin prior to the TEVAR in the SR group. Peri-operatively, the SR group had higher TLOS, TOR, number of procedure related hospitalizations, but lower fluoroscopy times compared to the TBE group (Table 2).
ConclusionWe have identified significant differences between SR-TEVAR and TBE during zone 2 TEVAR. These include increased hospital admissions, hospital days, operative times and a lower pre-operative hemoglobin prior to the TEVAR procedure. These preliminary findings suggest that there are significant benefits for endovascular revascularization of the LSA compared to surgical revascularization during zone 2 TEVAR.
| Table 1: Patient Demographics, Comorbidities and Intraoperative Variables Stratified by Treatment Strategy | |||
| Variable | TBE (n=24) | SR -TEVAR (n=31) | P |
| Age | 64.5±12.8 | 64.4±10.1 | 0.97 |
| Sex (male) | 16 (66.7) | 15 (48.4) | 0.18 |
| Race (Caucasian) | 20 (83.3) | 23 (74.2) | 0.42 |
| Race (African American) | 4 (16.7) | 6 (19.4) | 0.80 |
| Transfer from outside hospital | 5 (20.8) | 5 (16.1) | 0.65 |
| Insurance (commercial) | 12 (50) | 16 (51.6) | 0.91 |
| Insurance (Medicare) | 9 (37.5) | 12 (38.7) | 0.93 |
| Weight (kg) | 91.2±25.8 | 86.7±20.0 | 0.47 |
| Height (cm) | 172.7±10.0 | 172.0±9.3 | 0.77 |
| BMI | 30.5±8.0 | 29.2±6.0 | 0.47 |
| Prior Stroke | 2 (8.3) | 1 (3.2) | 0.41 |
| Prior MI | 3 (12.5) | 2 (6.5) | 0.44 |
| Prior CHF | 1 (4.1) | 6 (19.4) | 0.09 |
| COPD | 5 (20.8) | 6 (19.4) | 0.89 |
| Diabetes | 4 (16.7) | 4 (12.9) | 0.70 |
| Hypertension | 19 (79.2) | 29 (93.6) | 0.11 |
| Dialysis | 0 (0.0) | 1 (3.2) | 0.38 |
| Smoking History | 14 (58.3) | 21 (67.7) | 0.47 |
| Prior CABG | 1 (4.2) | 5 (16.1) | 0.16 |
| Prior CEA/CAS | 1 (4.2) | 0 (0.0) | 0.25 |
| Prior Abdominal Aneurysm Repair | 3 (12.5) | 4 (12.9) | 0.976 |
| Prior Aortic surgery | 8 (33.3) | 6 (19.4) | 0.24 |
| Pre-op hemoglobin (prior to TEVAR) | 13.2±1.9 | 11.8±2.1 | 0.01 |
| Pre-Op creatinine | 1.12±0.33 | 1.27±1.24 | 0.56 |
| Pre-Op eGFR(mL/min/1.73 m2) | 87.9±35.5 | 83.4±34.0 | 0.63 |
| Aortic pathology (acute dissection) | 10 (41.7) | 15 (48.4) | 0.62 |
| Aortic pathology (chronic dissection) | 2 (8.3) | 3 (9.7) | 0.86 |
| Aortic pathology (aneurysm) | 11 (45.8) | 12 (38.7) | 0.60 |
| Aortic pathology (intramural hematoma) | 1 (4.2) | 1 (3.2) | 0.85 |
| Proximal zone of disease (zone 1) | 1 (4.2) | 1 (3.2) | 0.85 |
| Proximal zone of disease (zone 2) | 14 (58.3) | 17 (54.8) | 0.77 |
| Proximal zone of disease (zone 3 or 4) | 9 (37.5) | 13 (41.9) | 0.74 |
| Distal zone of disease (zone 3 through 5) | 15 (62.5) | 18 (58.1) | 0.74 |
| Distal zone of disease (zone 6 through 11) | 9 (37.5) | 12 (38.7) | 0.93 |
| Table 2: Perioperative Outcomes Stratified by Treatment Strategy | |||
| Variable | TBE (n=24) | SR-TEVAR (n=31) | P |
| Elective | 24 (100) | 28 (90.3) | 0.12 |
| Urgent/Emergent | 0 (0.0) | 3 (9.7) | 0.12 |
| ASA class III | 10 (41.7) | 12 (38.7) | 0.82 |
| ASA class IV | 13 (54.2) | 19 (61.3) | 0.60 |
| Spinal drain | 15 (62.5) | 21 (67.7) | 0.69 |
| Number of Aortic Devices | 1.7±0.62 | 1.9±0.87 | 0.36 |
| EBL from TEVAR procedure (cc) | 218±167 | 134±314 | 0.24 |
| EBL from bypass procedure (cc) | 0±0 | 86±82 | <0.001 |
| Total EBL combined procedures (cc) | 218±167 | 220±379 | 0.98 |
| Iodinated contrast (cc) | 211.8±143.8 | 157.5±106.3 | 0.12 |
| Fluoroscopy time (min) | 38.0±20.3 | 16.8±9.7 | <0.001 |
| OR time for TEVAR procedure (min) | 203.5±79.4 | 117.3±65.7 | <0.001 |
| OR time for bypass procedure (min) | 0±0 | 132±35.5 | <0.001 |
| Total OR time combined procedures | 203.5±79.4 | 250.2±79.0 | 0.03 |
| One hospitalization to complete procedure | 24 (100) | 20 (64.5) | 0.001 |
| Two hospitalizations to complete procedure | 0 (0) | 11 (35.5) | 0.001 |
| Total LOS following TEVAR (days) | 5.2±3.6 | 6.5±5.4 | 0.32 |
| Total LOS following LSCA bypass [either until discharge or until TEVAR if performed during same hospitalization] (days) | 0±0 | 3.5±3.8 | <0.001 |
| Total LOS combined post bypass and TEVAR (days) | 5.2±3.6 | 9.9±7.2 | 0.004 |
| Re-operation | 1 (4.2) | 2 (6.5) | 0.71 |
| In-hospital mortality | 1 (4.2) | 0 (0.0) | 0.25 |
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