Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.
Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
Ann Thorac Surg. 2019 May;107(5):1372-1379. doi: 10.1016/j.athoracsur.2018.10.051. Epub 2018 Nov 30.
Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome.
Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions.
Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting.
Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion.
本研究旨在评估胸主动脉腔内修复术（TEVAR）过程中保留左锁骨下动脉（LSA）血流对结局的影响。
2001 年 8 月至 2016 年 10 月，176 例（平均年龄 61.3±15.8 岁）患者接受了完全覆盖 LSA 的 TEVAR。其中 55 例（31.3%）患者同时进行了 LSA 血运重建，121 例（68.7%）未进行。在三个研究机构回顾性采集围手术期数据进行统计分析。
整体院内和随访死亡率分别为 8.5%（n=15）和 9.1%（n=16），包括 88 例紧急和急症病例（50%）。对于整个队列，卒中（不考虑部位）和永久性截瘫的发生率分别为 6.8%和 6.3%。121 例未进行 LSA 血运重建的患者中，仅出现 12 例（9.9%）左上肢灌注不良。未进行 LSA 血运重建的患者左半球卒中的发生率明显高于左上肢灌注不良患者（16.7%比 3.7%，p=0.095）。多因素分析发现，未进行 LSA 血运重建（比值比[OR]3.779，95%置信区间[CI]：1.096 至 13.029，p=0.035）、两个或更多内支架（OR 3.814，95%CI：1.557 至 9.343，p=0.003）和冠状动脉疾病（OR 3.276，95%CI：1.262 至 8.507，p=0.015）是 TEVAR 完全覆盖 LSA 并置入支架后与手术相关的不良事件（左半球卒中、左上肢灌注不良和永久性截瘫）的独立危险因素。
每 10 例接受完全覆盖 LSA 支架置入但未进行血运重建的患者中就有 1 例出现左上肢灌注不良。未进行 LSA 血运重建、两个或更多内支架广泛覆盖主动脉以及冠状动脉疾病会增加永久性截瘫、左半球卒中和左上肢灌注不良的风险。患者应进行 LSA 血运重建，以预防左椎动脉相关的中枢神经系统并发症和维持左上肢灌注。
