title: Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair.
abstract: OBJECTIVE
  Thoracic endovascular aortic repair (TEVAR) of various pathologies has been associated with peri-interventional neurologic complication rates of up to 15%. The objective of this study was to determine the influence of the management of the left subclavian artery (LSA) on neurologic complications and to define subgroups that might benefit from LSA revascularization.
  
  
  METHODS
  The Medtronic Thoracic Endovascular Registry (MOTHER; Medtronic, Santa Rosa, Calif), consists of data from five sponsored trials and one institutional series incorporating 1010 patients undergoing TEVAR from 2002 to 2010. Perioperative stroke and spinal cord injury (SCI) rates were described according to the management of the LSA and presenting pathology. Multivariate analysis was performed to determine factors associated with perioperative neurologic complications.
  
  
  RESULTS
  Of 1002 patients included in the analysis, stroke occurred in 48 (4.8%), and SCI developed in 42 (4.2%) ≤ 30 days of surgery. The stroke rate was 2.2% in patients with no coverage of the LSA vs 9.1% with coverage alone and 5.1% in patients who underwent LSA revascularization before coverage (P < .001). This relationship was strongest in the aneurysm group. Coverage of the LSA without revascularization was independently associated with stroke (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.7-7.1), specifically in the posterior territory (OR, 11.7; 95% CI, 2.5-54.6), as was previous cerebrovascular accident (OR, 7.1; 95% CI, 2.2-23.1; P = .001), whereas a covered LSA was not associated with an increased risk of SCI.
  
  
  CONCLUSIONS
  Coverage of the LSA without revascularization is an important modifiable risk factor for stroke in patients undergoing TEVAR for a thoracic aortic aneurysm. Prior revascularization appears to protect against posterior circulation territory stroke.
authors.affiliation: St George's Vascular Institute, St George's Hospital, London, United Kingdom. Electronic address: benjamin.pattterson@me.com.
authors.forename: Benjamin O
authors.initials: BO
authors.lastname: Patterson
authors.affiliation: St George's Vascular Institute, St George's Hospital, London, United Kingdom.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Holt
authors.affiliation: Division of Cardiology, University Hospital Rostock, Rostock, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Nienaber
authors.affiliation: Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Fairman
authors.affiliation: Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Robin H
authors.initials: RH
authors.lastname: Heijmen
authors.affiliation: St George's Vascular Institute, St George's Hospital, London, United Kingdom.
authors.forename: Matt M
authors.initials: MM
authors.lastname: Thompson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D002986:Clinical Trials as Topic; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D065840:Protective Factors; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013119:Spinal Cord Injuries / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D013348:Subclavian Artery / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult