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INTRODUCTION: Beyond traditional indications, subclavian revascularization is increasingly performed to allow for aortic arch debranching in the setting of thoracic endovascular aortic repair (TEVAR). Endovascular approaches have also emerged as a therapeutic option for subclavian artery disease, perhaps altering the patient population undergoing open procedures. We leveraged prospectively-collected National Surgical Quality Improvement Program (NSQIP) data to delineate evolving stroke and mortality rates following carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) in this dynamic context.
METHODS: Utilizing the American College of Surgeons NSQIP database (2005-2010), adult patients who underwent CSB or SCT were examined. Patients admitted for emergency cases were excluded. Factors associated with the primary outcome (30-day post-operative stroke or death; CVA/D) were defined using univariable and multivariable analyses.
RESULTS: Eight hundred seventy-seven patients met inclusion and exclusion criteria, of whom 738 underwent CSB and 139 underwent SCT. Eighty-eight patients (10.0%) also underwent TEVAR. CSB comprised 41% of subclavian revascularizations associated with TEVAR and 89% of isolated subclavian revascularizations. The CSB and SCT group had similar baseline age (65.0 vs. 63.3, P = 0.67), race (Caucasian, 83.8% vs. 79.4%, P = 0.21), and prevalence of comorbid conditions. There were a greater proportion of TEVARs performed in the SCT group (37.4% vs. 4.9%, P < 0.01). The groups were otherwise similar in demographic characteristics and prevalence of comorbid conditions. Overall stroke, mortality, and combined CVA/D rates were 3.5% (n=31), 3.3% (n=29), and 5.8% (n=51), respectively. Surgical approach did not affect CVA/D rate (OR, 1.51; 95% CI, 0.71 - 3.19. P = 0.28), however increasing age (adjusted odds ratio (OR), 1.06; 95% confidence interval (CI), 1.03 - 1.10. P < 0.01), CHF (OR, 3.49; 95% CI, 1.04 - 11.64. P = 0.04), and American Society of Anesthesiologists (ASA) class > III (OR, 2.06; 95% CI, 1.11 - 3.83. P = 0.02) were significantly associated with CVA/D in the overall group. The CVA/D rate was 10.2% (n=9) for revascularization in conjunction with TEVAR and 5.3% (n=42) for isolated reconstruction (P = 0.06). Without excluding emergency cases, the TEVAR cohort's CVA/D rate was 14.7%. For patients undergoing TEVAR, no factors were significantly associated with CVA/D including surgical approach (SCT vs. CSB. OR, 0.52; 95% CI, 0.13, 2.08. P = 0.35). For patients undergoing isolated revascularization, increasing age (OR, 1.06; 95% CI, 1.03 - 1.10. P < 0.01), and non-independent functional status (OR, 3.49; 95% CI, 1.41 - 8.68. P < 0.01) were significantly associated with CVA/D.
CONCLUSIONS: Despite improvements in surgical, anesthetic, and critical care technology, open cervical reconstruction of the subclavian artery for occlusive disease carries a persistent combined stroke and death rate > 5% in this contemporary work. With TEVAR this rate is as high as 10.2%. There was no significant difference in CVA/D by surgical approach after adjustment for other factors. CVA/D continues to complicate contemporary CSB and SCT, especially among elderly and non-independent patient subsets.

Table. Outcome, stratified by TEVAR and surgical approach

	CVA/D	Death	CVA
All patients (n = 877)	51 (5.8%)	29 (3.3%)	31 (3.5%)
TEVAR
Overall (n = 88)	9 (10.2%)	6 (6.8%)	5 (5.7%)
CSB (n = 36)	5 (13.9%)	3 (8.3%)	3 (8.3%)
SCT (n = 52)	4 (7.7%)	3 (5.8%)	2 (3.9%)
Non-TEVAR
Overall (n = 789)	42 (5.3)	23 (2.9)	26 (3.3)
CSB (n = 702)	36 (5.1)	20 (2.9)	22 (3.1)
SCT (n = 87)	6 (6.9)	3 (3.5)	4 (4.6)