Conway Allan M, Qato Khalil, Nhan Nguyen Tran N, Giangola Gary, Carroccio Alfio
Department of Surgery, 5945Lenox Hill Hospital, Northwell Health, New York, NY, USA.
Vasc Endovascular Surg. 2020 Oct;54(7):586-591. doi: 10.1177/1538574420942353. Epub 2020 Jul 23.
Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD.
The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards.
Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( = .16), spinal cord ischemia ( = 1.00), or death ( = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, = .04).
Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.
胸主动脉腔内修复术（TEVAR）中左锁骨下动脉（LSA）血运重建仍存在争议。不进行血运重建而覆盖左锁骨下动脉可导致中风和死亡。TEVAR在慢性B型主动脉夹层（cTBD）的治疗中越来越受欢迎。利用血管质量倡议（VQI）数据库，我们回顾了TEVAR治疗cTBD时LSA血运重建的结果。
VQI登记处识别出2010年7月至2016年7月接受TEVAR治疗的5683例患者，其中包括208例cTBD修复术。我们根据血管外科学会报告标准分析结果。
208例患者中，150例（72.1%）为男性，中位年龄65.0岁（四分位间距[IQR]，55.0 - 72.0）。动脉瘤中位直径为5.7 cm（IQR，5.0 - 6.5 cm）。131例（63.0%）患者有LSA通畅情况的数据。25例（19.1%）LSA闭塞且未进行血运重建，而106例（80.9%）保持通畅或进行了血运重建。所有131例（100%）患者均成功植入器械。维持LSA通畅不影响脑血管意外发生率（P = 0.16）、脊髓缺血发生率（P = 1.00）或死亡率（P = 1.00）。在分析98例择期病例亚组时，这一结果也无统计学意义。内漏发生率无差异。对LSA进行任何干预（血运重建或闭塞）都会导致手术时间延长（203.6分钟对163.7分钟，P = 0.04）。
TEVAR治疗cTBD时维持LSA通畅在围手术期发病率或内漏方面无优势。在该队列中可安全地闭塞LSA，血运重建仅适用于解剖结构影响重要器官灌注的患者。
