title: Outcomes of Thoracic Endovascular Aortic Repair and Subclavian Revascularization Techniques.
abstract: BACKGROUND
  Practice guidelines for management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) are based on low-quality evidence, and there is limited literature that addresses optimal revascularization techniques. The purpose of this study was to compare outcomes of LSA coverage during TEVAR and revascularization techniques.
  
  
  METHODS
  We performed a single-center retrospective cohort study from 2001 to 2013. Patients were categorized by LSA revascularization and by revascularization technique, carotid-subclavian bypass (CSB), or subclavian-carotid transposition (SCT). Thirty-day and mid-term stroke, spinal cord ischemia, vocal cord paralysis, upper extremity ischemia, primary patency of revascularization, and mortality were compared.
  
  
  RESULTS
  Eighty patients underwent TEVAR with LSA coverage, 25% (n = 20) were unrevascularized and the remaining patients underwent CSB (n = 22 [27.5%]) or SCT (n = 38 [47.5%]). Mean follow-up time was 24.9 months. Comparisons between unrevascularized and revascularized patients were significant for a higher rate of 30-day stroke (25% vs 2%; p = 0.003) and upper extremity ischemia (15% vs 0%; p = 0.014). However, there was no difference in 30-day or mid-term rates of spinal cord ischemia, vocal cord paralysis, or mortality. There were no statistically significant differences in 30-day or midterm outcomes for CSB vs SCT. Primary patency of revascularizations was 100%. Survival analysis comparing unrevascularized vs revascularized LSA was statistically significant for freedom from stroke and upper extremity ischemia (p = 0.02 and p = 0.003, respectively). After adjustment for advanced age, urgency, and coronary artery disease, LSA revascularization was associated with lower rates of perioperative adverse events (odds ratio = 0.23; p = 0.034).
  
  
  CONCLUSIONS
  During TEVAR, LSA coverage without revascularization is associated with an increased risk of stroke and upper extremity ischemia. When LSA coverage is required during TEVAR, CSB and SCT are equally acceptable options.
authors: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of General Surgery, Boston University School of Medicine, Boston, MA.
authors: Kimberly C
authors: KC
authors: Zamor
authors: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors: Mark K
authors: MK
authors: Eskandari
authors: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors: Heron E
authors: HE
authors: Rodriguez
authors: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors: Karen J
authors: KJ
authors: Ho
authors: Heart and Vascular Center, St Vincent Healthcare, Billings, MT.
authors: Mark D
authors: MD
authors: Morasch
authors: Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address: awhoel@nmh.org.
authors: Andrew W
authors: AW
authors: Hoel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000601:surgery*; D017541:Aneurysm, False / Q000601:surgery*; D001013:Aorta, Thoracic / Q000293:injuries / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002339:Carotid Arteries / Q000601:surgery; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D012189:Retrospective Studies; D013348:Subclavian Artery / Q000601:surgery*; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000379:methods*; D057772:Vascular System Injuries / Q000601:surgery*; D055815:Young Adult