Mark D. Peterson, Grayson H. Wheatley, Jacques Kpodonu, James P. Williams, Venkatesh G. Ramaiah, Julio A. Rodriguez-Lopez, Edward B. Diethrich; Cardiovascular Surgery, Arizona Heart Institute, Phoenix, AZ
Objective: Increasing experience with thoracic aortic stent grafts has lead to a more aggressive approach to thoracic aortic pathologies in the distal aortic arch and proximal descending thoracic aorta. To increase the length of the proximal landing zone, it is sometimes necessary to cover the left subclavian artery (LSA) with the thoracic stent-graft which introduces the risk of retrograde filling of the excluded aorta from the LSA. It is currently unclear how best to manage these patients to prevent persistent risk of aneurysm expansion or rupture. We report our experience with a minimally invasive endovascular repair of the covered LSA.Methods: We reviewed prospectively gathered data on all IDE approved patients undergoing thoracic aortic stent grafting at our institution from 2000 to 2006 (n=304 patients). Patients had standard surveillance with a contrast enhanced CT scan on the first postoperative day, and during follow-up at 1, 6 and 12 months.
Results: We implanted 307 thoracic stent grafts during the study: Medtronic Talent (n=31) or Gore TAG (n=276). The LSA was covered in 24% of patients (n=73), of which 19.2% had preoperative carotid-subclavian bypass (n=14). In this group, stent grafts were implanted for a variety of pathologies: Type B dissection (n=32), aneurysm (n=24), pseudoaneurysm (n=7), traumatic disruption (n=2), aortobronchial fistula (n=2), penetrating atherosclerotic ulcer (n=2), treatment of proximal Type I endoleak (n=2) and contained rupture (n=1). The 30 day mortality was 9.6% (n=7) and the incidence of left arm claudication was 6.8% (n=5), necessitating post-operative carotid-subclavian bypass in two patients. Eleven patients (15.1%) had either a type I (n=6) or II (n=5) endoleak diagnosed during follow-up. Coverage of the left subclavian accounted for 60% of the Type II endoleaks (n=3), while patent intercostals accounted for the rest (n=2). Type II endoleaks associated with left subclavian coverage were successfully treated by either retrograde coil embolization from the left brachial artery (n=2) or left subclavian ligation (n=1).
Conclusion: Coverage of the left subclavian artery during thoracic aortic stent grafting is associated with a low incidence of arm complications and Type II endoleaks. All Type II endoleaks were successfully treated by either retrograde coil embolization or ligation of the left subclavian artery. Successful treatment of endoleaks may reduce the risk of aneurysm expansion or rupture.
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