Bradshaw Rhiannon J, Ahanchi S Sadie, Powell Obie, Larion Sebastian, Brandt Colin, Soult Michael C, Panneton Jean M
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va.
J Vasc Surg. 2017 May;65(5):1270-1279. doi: 10.1016/j.jvs.2016.10.111. Epub 2017 Feb 16.
The best management strategy for the left subclavian artery (LSA) in pathologic processes of the aorta requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSA coverage with or without revascularization as well as the different means of LSA revascularization.
A retrospective chart review was conducted of patients with any aortic diseases who underwent zone 2 TEVAR deployment from 2007 to 2014. Primary end points included 30-day stroke and 30-day spinal cord injury (SCI). Secondary end points were 30-day procedure-related reintervention, freedom from aorta-related reintervention, aorta-related mortality, and all-cause mortality.
We identified 96 patients with zone 2 TEVAR who met our inclusion criteria. The mean age of the patients was 62 years, with 61.5% male. Diseases included acute aortic dissections (n = 25), chronic aortic dissection with aneurysmal degeneration (n = 22), primary aortic aneurysms (n = 21), penetrating aortic ulcers/intramural hematomas (n = 17), and traumatic aortic injuries (n = 11). Strategies for the LSA included coverage with revascularization (n = 54) or without revascularization (n = 42). Methods of LSA revascularization included laser fenestration with stenting (n = 33) and surgical revascularization: transposition (n = 10) or bypass (n = 11). Of the 54 patients with LSA revascularization, 44 (81.5%) underwent LSA intervention at the time of TEVAR and 10 (18.5%) at a mean time of 33 days before TEVAR (range, 4-63 days). For the entire cohort, the overall incidence of 30-day stroke was 7.3%; of 30-day SCI, 2.1%; and of procedure-related reintervention, 5.2%. At a mean follow-up of 24 months (range, 1-79 months), aorta-related reintervention was 15.6%, aorta-related mortality was 12.5%, and all-cause mortality was 29.2%. The 30-day stroke rate was highest for LSA coverage without revascularization (6/42 [14.3%]) compared with any form of LSA revascularization (1/54 [1.9%]; P = .020), with no difference between LSA interventions done synchronously with TEVAR (1/44 [2.3%]) vs metachronously with TEVAR (0/10 [0%]; P = .63). There was no significant difference in 30-day SCI in LSA coverage without revascularization (2/42 [4.8%]) vs with revascularization (0/54 [0%]; P = .11). There was no difference in aorta-related reintervention, aorta-related mortality, or all-cause mortality in coverage without revascularization (5/42 [11.9%], 6/42 [14.3%], and 14/42 [33.3%]) vs with revascularization (10/54 [18.5%; P = .376], 6/54 [11.1%; P = .641], and 14/54 [25.9%; P = .43], respectively). After univariate and multivariable analysis, we identified LSA coverage without revascularization as associated with a higher rate of 30-day stroke (hazard ratio, 17.2; 95% confidence interval, 1.3-220.4; P = .029).
Our study suggests that coverage of the LSA without revascularization increases the risk of stroke and possibly SCI.
在需要进行2区胸段血管腔内主动脉修复术（TEVAR）的主动脉病理过程中，左锁骨下动脉（LSA）的最佳管理策略仍存在争议。我们比较了有或无血运重建情况下的LSA覆盖情况以及LSA血运重建的不同方式。
对2007年至2014年接受2区TEVAR植入术的任何主动脉疾病患者进行回顾性病历审查。主要终点包括30天卒中及30天脊髓损伤（SCI）。次要终点为30天与手术相关的再次干预、无主动脉相关再次干预、主动脉相关死亡率及全因死亡率。
我们确定了96例符合纳入标准的2区TEVAR患者。患者的平均年龄为62岁，男性占61.5%。疾病包括急性主动脉夹层（n = 25）、慢性主动脉夹层伴动脉瘤样退变（n = 22）、原发性主动脉瘤（n = 21）、穿透性主动脉溃疡/壁内血肿（n = 17）及创伤性主动脉损伤（n = 11）。LSA的策略包括有血运重建的覆盖（n = 54）或无血运重建的覆盖（n = 42）。LSA血运重建的方法包括激光开窗加支架置入（n = 33）及手术血运重建：转位（n = 10）或旁路移植（n = 11）。在54例进行LSA血运重建的患者中，44例（81.5%）在TEVAR时进行了LSA干预，10例（18.5%）在TEVAR前平均33天（范围4 - 63天）进行了干预。对于整个队列，30天卒中的总体发生率为7.3%；30天SCI为2.1%；与手术相关的再次干预为5.2%。平均随访24个月（范围1 - 79个月）时，主动脉相关再次干预为15.6%，主动脉相关死亡率为12.5%，全因死亡率为29.2%。与任何形式的LSA血运重建相比（1/54 [1.9%]；P = .020），无血运重建的LSA覆盖的30天卒中率最高（6/42 [14.3%]），TEVAR同步进行LSA干预（1/44 [2.3%]）与TEVAR异时进行LSA干预（0/10 [0%]；P = .63）之间无差异。无血运重建的LSA覆盖（2/42 [4.8%]）与有血运重建（0/54 [0%]；P = .11）的30天SCI无显著差异。无血运重建的覆盖（5/42 [11.9%]，6/42 [14.3%]，14/42 [33.3%]）与有血运重建（10/54 [18.5%；P = .376]，6/54 [11.1%；P = .641]，14/54 [25.9%；P = .43]）在主动脉相关再次干预、主动脉相关死亡率或全因死亡率方面无差异。经过单因素和多因素分析，我们确定无血运重建的LSA覆盖与30天卒中发生率较高相关（风险比，17.2；95%置信区间，1.3 - 220.4；P = .029）。
我们的研究表明，无血运重建的LSA覆盖会增加卒中风险，可能还会增加SCI风险。
