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Local Complications Of Cervical Debranching During Thoracic And Arch Endovascular Aortic Repair; Benchmarking The “Gold Standard” In The Branched Tevar Era
Michelle Manesh, MD, Alexander DiBartolomeo, MD, Markian Bojko, MD, Zachary Rengel, MD, Sebouh Bazikian, MD, Alyssa Pyun, MD, Miguel Manzur, MD, Gregory Magee, MD, Fernando Fleischman, MD, Sukgu Han, MD.
University of Southern California Division of Vascular Surgery and Endovascular Therapy, Los Angeles, CA, USA.
Objectives: Cervical debranching (CD) of supra-aortic trunk (SAT) vessels is used to extend proximal seal zone during thoracic endovascular aortic repair (TEVAR). Prior research has focused on left subclavian artery revascularization during zone 2 TEVAR; outcomes of more complex CD are not well described. We provide a comparative analysis of outcomes after standard and complex CD during TEVAR, focusing on local complications associated with CD.
Methods: A retrospective review of patients who underwent CD and TEVAR at a regional aortic center between September 2017 and August 2023 was performed. Patients were grouped based on type of CD operation. Standard CD were operations involving a unilateral subclavian or axillary artery, and complex CD were operations involving multiple SAT vessels and/or aberrant arch anatomy. The primary endpoint was local complications within 30 days, defined as nerve injury, hematoma, chyle leak, seroma, wound infection, or wound dehiscence. Secondary endpoints included graft patency, reintervention, major adverse events, and survival. Outcomes were compared between groups.
Results: 82 patients were included (63 standard CD, 19 complex CD). Patient characteristics and comorbidities were similar between groups. Complex CD had higher mean operative time (260.2±59.5 minutes vs. 158.9±63.4 minutes, p<0.001) and was more likely to require transfusion (0 units [0-2.3] vs. 0 units [0-0], p=0.005). Local complications occurred more frequently after complex CD (52.6% vs. 25.4%, p=0.025), as did major adverse events (57.9% vs. 28.6%, p=0.019) and 30-day mortality (21.1% vs. 3.2%, p=0.009). At mean follow-up of 465 days, target vessel patency was 100% in both groups. Kaplan-Meier 1-year survival probability was higher for standard CD (90%) compared to complex CD (69%) (log-rank p=0.038). Univariate regression showed that occurrence of local complications portended an increased risk of reintervention (OR=20.3, 95% CI:2.3-175.6), 30-day mortality (OR=12.9, 95% CI:1.4-116.7), and all-cause mortality (OR=3.7, 95% CI:1.1-12.1).
Conclusions: Complex CD involving multiple SAT vessels and/or aberrant anatomy is associated with increased risk of local complications, major adverse events, and early mortality. Local complications are associated with reintervention and mortality. These results suggest a need for ongoing advancement of SAT incorporation techniques during TEVAR.
Table I. Comparison of outcomes between standard and complex CD
| | | | |
| Total (N=82) | Standard CD (N=63) | Complex CD (N=19) | p-value |
| Short Term Outcomes |
| Operative time (min) | 188.7 ± 77.2 | 158.9 ± 63.4 | 260.2 ± 59.5 | <0.001 |
| Estimated blood loss (mL) | 100 (100 – 200) | 100 (100 – 200) | 200 (75 – 750) | 0.269 |
| Transfusion (units) | 0 (0 – 0) | 0 (0 – 0) | 0 (0 – 2.3) | 0.005 |
| | | | |
| Local Complications | 26 (31.70%) | 16 (25.4%) | 10 (52.6%) | 0.025 |
| Nerve injury | 13 (15.85%) | 9 (14.3%) | 4 (21.1%) | 0.479 |
| Wound infection | 3 (3.66%) | 3 (4.8%) | 0 | 0.33 |
| Hematoma | 8 (9.76%) | 4 (6.3%) | 4 (21.1%) | 0.058 |
| Chylous leak | 5 (6.10%) | 3 (4.8%) | 2 (10.5%) | 0.357 |
| Seroma | 2 (2.44%) | 1 (1.6%) | 1 (5.3%) | 0.363 |
| Wound dehiscence | 0 | 0 | 0 | -- |
| | | | |
| Major adverse events | 29 (35.4%) | 18 (28.6%) | 11 (57.9%) | 0.019 |
| Myocardial infarction | 7 (8.5%) | 4 (6.3%) | 3 (15.8%) | |
| Prolonged intubation | 6 (7.3%) | 3 (4.8%) | 3 (15.8%) | |
| Pneumonia | 6 (7.3%) | 4 (6.3%) | 2 (10.5%) | |
| Acute kidney injury | 22 (26.8%) | 15 (23.8%) | 7 (36.8%) | |
| Dialysis | 5 (6.1%) | 4 (6.3%) | 1 (5.3%) | |
| Stroke | 5 (6.1%) | 4 (6.3%) | 1 (5.3%) | |
| Spinal cord ischemia | 4 (4.9%) | 2 (3.2%) | 2 (10.5%) | |
| Venous thromboembolism | 2 (2.4%) | 1 (1.6%) | 1 (5.3%) | |
| | | | |
| 30-day readmission | 7 (8.54%) | 4 (6.3%) | 3 (15.8%) | 0.197 |
| 30-day mortality | 6 (7.3%) | 2 (3.2%) | 4 (21.1%) | 0.009 |
|
| Mid-term Outcomes |
| Mean follow-up (days) | 464.9 ± 554.6 | 480.4 ± 578.6 | 412.7 ± 476.6 | 0.644 |
| Target vessel patency | 100% | 100% | 100% | - |
| Reintervention | 8 (9.8%) | 4 (6.3%) | 4 (21.1%) | 0.058 |
| All-cause mortality | 14 (17.07%) | 8 (12.7%) | 6 (31.6%) | 0.055 |
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