Left subclavian artery revascularization as part of thoracic stent grafting.
OBJECTIVE
Intentional covering of the left subclavian artery (LSA) as part of thoracic endovascular aortic repair (TEVAR) can cause (posterior) strokes or left arm malperfusion. LSA revascularization can be done as prophylaxis against, or as treatment of, these complications. We report our experience with the surgical technique, indications and the results of LSA revascularization.


METHODS
Between 2000 and 2013, 51 patients of 444 patients who were treated by TEVAR, had LSA revascularization. All elective patients had a preoperative work-up with magnetic resonance angiography to evaluate the circle of Willis. In all, surgical access was through a left supraclavicular incision only.


RESULTS
The majority (90%) had prophylactic LSA revascularization because of incomplete circle of Willis and or dominant left vertebral artery (LVA) (n=29), patent left internal mammary artery (n=1), prevention spinal cord ischaemia (SCI) (n=2), prevention left arm ischaemia due to small LVA (n=2) and LVA origin in arch (n=1). Fourteen percent had secondary revascularization, either immediate because of malperfusion of the left arm (n=2) or late after TEVAR because of persisting left arm claudication (n=5). In 12 patients, the following early complications were observed: re-exploration for bleeding, n=1; left recurrent nerve paralysis, n=2; left phrenic nerve paralysis, n=1; left sympathetic chain neuropraxia, resulting in Horner's syndrome, n=3; Chyle duct lesions, resulting in persistent Chyle leakage, n=3. Neither strokes nor SCI was observed. One patient experienced occlusion of the bypass at 6 months.


CONCLUSIONS
The present study shows that the procedure of LSA revascularization as part of TEVAR is safe with low morbidity consisting of mainly (transient) nerve palsy.
Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands n.saouti@antoniusziekenhuis.nl n.saouti@vumc.nl.
Nabil
N
Saouti
Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.
Vikash
V
Hindori
Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.
William J
WJ
Morshuis
Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, Netherlands.
Robin H
RH
Heijmen
D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D015607:Stents; D013348:Subclavian Artery / Q000601:surgery*
Left subclavian artery revascularization; Malperfusion; Neuropraxia; Stroke; Thoracic endovascular aortic repair