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• W4280496973 abstract "Left subclavian artery revascularization (LSAR) during thoracic endovascular aneurysm repair (TEVAR) is an area of constant debate. Zone 2 aortic pathologies necessitate LSA coverage. Recent studies demonstrated no added immediate benefit for LSAR in chronic type B dissection. We sought to evaluate short and long-term outcomes after LSAR in patients with aneurysmal and nonaneurysmal aortic diseases. We explored the Vascular Quality Initiative registry (2014-2021). We included nontraumatic aortic disease requiring zone two proximal coverage. Primary outcomes were postoperative spinal cord ischemia (SCI), arm ischemia, and 30-day and 4-year mortality, as well as 2-year reintervention. We divided the cohort into three groups: LSA covered (LSA-no Rx), LSA revascularized with endovascular options such as stenting, fenestration, or snorkel (LSA-Endo), and LSA surgically revascularized with carotid-subclavian bypass or transposition (LSA-bypass). We adjusted for patients’ demographics, comorbidities, prior aortic surgery, intraoperative mean arterial pressure, prophylactic placement of a spinal drain, prior coronary artery bypass grafting, preoperative laboratory tests, procedure time, and symptomatic presentation. We identified 3107 who met the inclusion criteria; 42.8% had the LSA covered, 47% underwent surgical revascularization, and 10.2% were LSA-endo. LSA-endo group was more likely to be older than 65 years, have aneurysmal pathology, and be asymptomatic at time of presentation. Symptomatic patients were less likely to undergo LSAR, whether endo or bypass. The LSA-bypass group was more likely to be hypertensive, had prior aortic surgery, or receive spinal drain (Table). Adjusted odds of SCI were significantly higher if no LSAR was done (adjusted odds ratio [aOR], 1.71; 95% confidence interval [CI], 1.27-2.30; P < .001 compared with LSA-bypass). The odds of SCI were similar between LSA-endo and LSA-bypass groups (aOR, 1.08; 95% CI, 0.55-2.13; P = .82]. Similarly, the odds of vertebrobasilar stroke was higher in LSA-no Rx group (aOR, 1.77; 95% CI, 1.12-2.78; P = .014) and equivalent in the LSA-endo group (aOR, 1.09; 95% CI, 0.50-2.39; P = .83) compared with LSA-bypass patients. Upper extremity ischemia and 30-day mortality showed similar patterns. The 4-year survival was slightly but significantly superior in the LSA-bypass group 83.8% versus 80.2% in LSA-endo and 82.0% in LSA-no Rx (P = .017). Adjusted hazard ratio (aHR) of 4-year mortality was significantly higher in LSA-no Rx group (aHR, 1.35; 95% CI, 1.08-1.69; P = .010) and LSA-endo (aHR, 1.48; 95% CI, 1.05-2.07; P = .025) compared with LSA-bypass patients. The 2-year freedom from reintervention was similar in all treatment groups (LSA-no Rx, 91.6%; LSA-endo, 90.7%; LSA-bypass, 91.3%; P = .95) (Figure). Likewise, the aHR was not statistically significant. LSA revascularization in patients requiring zone two proximal coverage does protect against spinal cord ischemia and provides long-term survival benefit over no revascularization. Reintervention rates were similar in patients with and without LSAR, indicating LSAR might provide durable and safe repair.TableVariableNo LSA Rx (n = 1330, 42.8%)Endo (n = 317, 10.2%)Bypass (n = 1460, 47%)P valueAge >65 years578 (43.5%)170 (53.6%)715 (49.0%).001Female gender442 (33.2%)114 (36%)495 (33.9%).65Non-White race529 (39.8%)132 (41.6%)598 (41.0%).75Hispanic91 (6.9%)20 (6.4%)89 (6.1%).73Pathology Nonaneurysmal1218 (91.6%)275 (86.8%)1266 (86.8%)<.0001 Aneurysmal112 (8.4%)42 (13.3%)193 (13.2%)History of stroke138 (10.4%)31 (9.8%)155 (10.6%).91Congestive heart failure155 (11.7%)33 (10.4%)164 (11.2%).81Chronic obstructive pulmonary disease202 (15.2%)46 (14.5%)237 (16.2%).64Diabetes mellitus135 (10.2%)38 (12.0%)158 (10.8%).62History of coronary artery bypass grafting74 (5.6%)20 (6.3%)112 (7.7%).08Hypertension1157 (88.4%)286 (9.8%)1320 (92.0%).006Coronary artery disease163 (12.3%)45 (14.2%)226 (15.5%).05American Society of Anesthesiologists587 (44.2%)156 (49.4%)791 (54.2%)<.0001P2y12 antagonist74 (5.6%)32 (10.1%)73 (5.0%).002Presentation Asymptomatic416 (31.3%)160 (50.5%)678 (46.4%)<.0001 Symptomatic914 (68.7%)157 (49.5%)782 (53.6%)Prior aortic surgery290 (21.8%)80 (25.2%)395 (27.1%).006Prophylactic spinal drain581 (43.7%)148 (46.7%)787 (54.0%)<.0001Procedure time, hours2.48 ± 1.702.68 ± 1.402.80 ± 1.70<.0001Estimated blood loss, liters0.21 ± 0.400.16 ± 0.180.25 ± 0.51<.003Preoperative hemoglobin12.11 ± 2.1312.16 ± 2.1011.85 ± 2.05.002Preoperative creatinine1.26 ± 1.201.27 ± 1.271.13 ± 0.77.003Boldface entries indicate statistical significance. Open table in a new tab" @default.
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• W4280496973 date "2022-06-01" @default.
• W4280496973 modified "2023-09-27" @default.
• W4280496973 title "Left Subclavian Artery Revascularization During Thoracic Endovascular Aneurysm Repair (TEVAR) Is Associated With Improved Long-Term Survival Without Significant Risk For Reintervention" @default.
• W4280496973 doi "https://doi.org/10.1016/j.jvs.2022.03.568" @default.
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