title: Intentional coverage of the left subclavian artery during endovascular repair of traumatic descending thoracic aortic transection.
abstract: OBJECTIVE
  This single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center.
  
  
  METHODS
  From January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was <2 cm. At 12, 24, and 72 hours postoperatively, clinical and neurologic evaluation including transcranial Doppler insonation of the brachial artery was performed. A decrease in peak systolic velocity (PSV) >60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up.
  
  
  RESULTS
  Thirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter <3 mm (P < .0001). A significant correlation was found between the degree of PSV reduction and left arm symptoms (P < .0001). There was an improvement in ischemic arm symptoms (P < .0001) during mean follow-up of 36 months (range, 6-65 months), with only one patient (4.2%) presenting with severe claudication. Freedom from reintervention at 48 months was 93.5%. No signs of endoleaks or graft migrations were detected on computerized tomographic angiography control scans.
  
  
  CONCLUSIONS
  Coverage of the LSA during TEVAR for traumatic aortic injuries appears to be a feasible, safe method for extending the endograft landing zone without increasing the risk of paraplegia, stroke, or left arm ischemia. Left vertebral artery diameter can be used to identify patients at risk for postoperative left arm ischemia.
authors.affiliation: Section of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy. michele.antonello.1@unipd.it
authors.forename: Michele
authors.initials: M
authors.lastname: Antonello
authors.forename: Mirko
authors.initials: M
authors.lastname: Menegolo
authors.forename: Carlo
authors.initials: C
authors.lastname: Maturi
authors.forename: Alberto
authors.initials: A
authors.lastname: Dall'antonia
authors.forename: Sandro
authors.initials: S
authors.lastname: Lepidi
authors.forename: Anna Chiara
authors.initials: AC
authors.lastname: Frigo
authors.forename: Franco
authors.initials: F
authors.lastname: Grego
authors.forename: Paolo
authors.initials: P
authors.lastname: Frigatti
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001013:Aorta, Thoracic / Q000293:injuries* / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000209:etiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013348:Subclavian Artery / Q000601:surgery*; D062606:Tertiary Care Centers; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D034941:Upper Extremity / Q000098:blood supply; D057772:Vascular System Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D055815:Young Adult