title: Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization.
abstract: OBJECTIVE
  This study assessed the risk of left subclavian artery (LSA) coverage and the role of revascularization in a large population of patients undergoing thoracic endovascular aortic aneurysm repair.
  
  
  METHODS
  A retrospective multicenter review of 1189 patient records from 2000 to 2010 was performed. Major adverse events evaluated included cerebrovascular accident (CVA) and spinal cord ischemia (SCI). Subgroup analysis was performed for noncovered LSA (group A), covered LSA (group B), and covered/revascularized LSA (group C).
  
  
  RESULTS
  Of 1189 patients, 394 had LSA coverage (33.1%), and 180 of these patients (46%) underwent LSA revascularization. In all patients, emergency operations (9.5% vs 4.3%; P=.001), renal failure (12.7% vs 5.3%; P=.001), hypertension (7% vs 2.3%; P=.01), and number of stents placed (1=3.7%, 2=7.4%, ≥3=10%; P=.005) were predictors of SCI. History of cerebrovascular disease (9.6% vs 3.5%; P=.002), chronic obstructive pulmonary disease (9.5% vs 5.4%; P=.01), coronary artery disease (8.5% vs 5.3%; P=.03), smoking (8.9% vs 4.2%) and female gender (5.3% men vs 8.2% women; P=.05) were predictors of CVA. Subgroup analysis showed no significant difference between groups B and C (SCI, 6.3% vs 6.1%; CVA, 6.7% vs 6.1%). LSA revascularization was not protective for SCI (7.5% vs 4.1%; P=.3) or CVA (6.1% vs 6.4%; P=.9). Women who underwent revascularization had an increased incidence of CVA event compared with all other subgroups (group A: 5.6% men, 8.4% women, P=.16; group B: 6.6% men, 5.3% women, P=.9; group C: 2.8% men, 11.9% women, P=.03).
  
  
  CONCLUSIONS
  LSA coverage does not appear to result in an increased incidence of SCI or CVA event when a strategy of selective revascularization is adopted. Selective LSA revascularization results in similar outcomes among the three cohorts studied. Revascularization in women carries an increased risk of a CVA event and should be reserved for select cases.
authors.affiliation: Department of Surgery NYU Langone Medical Center, New York, NY 10016, USA. thomas.maldonado@nyumc.org
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Maldonado
authors.forename: David
authors.initials: D
authors.lastname: Dexter
authors.forename: Caron B
authors.initials: CB
authors.lastname: Rockman
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Veith
authors.forename: Karan
authors.initials: K
authors.lastname: Garg
authors.forename: Frank
authors.initials: F
authors.lastname: Arko
authors.forename: Hernan
authors.initials: H
authors.lastname: Bertoni
authors.forename: Sharif
authors.initials: S
authors.lastname: Ellozy
authors.forename: William
authors.initials: W
authors.lastname: Jordan
authors.forename: Edward
authors.initials: E
authors.lastname: Woo
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D016009:Chi-Square Distribution; D017558:Elective Surgical Procedures; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D015994:Incidence; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D020760:Spinal Cord Ischemia / Q000453:epidemiology; D020521:Stroke / Q000453:epidemiology; D013348:Subclavian Artery / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult