Left Subclavian RetroSandwich Technique for Zone 1 and 2 Extent Thoracic Endovascular Aneurysm Repair
Lauren Grimsley, Sam J Tyagi, Dong Lee, Tana Repella, Eleftherios Xenos, David J Minion
University of Kentucky, Lexington, KY
Background: Endovascular options for left subclavian artery preservation during Zone 2 TEVAR include fenestrations, parallel grafts and branch grafts. This study’s objective was to review outcomes for left subclavian preservation utilizing a retrograde sandwich parallel graft technique.
Methods: The technique consists of initial placement of an aortic endoprosthesis in Zone 3 of the descending thoracic aorta, followed by a retrograde oriented extension into the left subclavian artery from contralateral femoral access in parallel with an aortic extension into the arch (Figure). Adjuvant Eye of the Tiger molding of the subclavian stent was performed in aneurysmal cases to eliminate gutter leaks. All consecutive cases performed at our institution from 2014 to 2022 were reviewed retrospectively and compared to the reported outcomes of the combined Aneurysm and Dissection cohorts from the Gore Thoracic Branch Endoprosthesis (TBE) FDA trial using chi-square analysis.
Results: Forty-six cases were identified with longest follow up of eight years. Indications were aneurysm in 9, dissection in 32, and other in 5. Outcomes for procedural success, 30-day stroke, 30-day lesion related mortality, 30-day new dissection, late Type I/III endoleak and late rupture were similar to TBE (Table). Twelve patients would have been excluded from the TBE trial for general conditions, including connective tissue disorder, IV drug use, and pregnancy. Fifteen would have been excluded for Zone 1 involvement. Each of these fifteen underwent left carotid debranching by carotid-carotid transposition without additional significant morbidity. The average length of Zone 1 was 13 mm in this cohort. Placement of an appropriately sized TBE device in the left common carotid (i.e., with adjuvant subclavian debranching) would have encroached on the innominate orifice in all cases.
Conclusions: This large single center experience shows that protocolized parallel endografts with adjuvant Eye of the Tiger molding can provide comparable results to branch grafts of similar construct. This technique should be considered if appropriately configured branched devices are unavailable and/or as a bailout for procedural failures. In addition, it is likely that left carotid debranching will have more utility than left subclavian debranching in cases of Zone 1 involvement.
| RetroSandwich | Thoracic Branch Endoprosthesis | p value | |
| Number | 46 | 216 | |
| Procedural Failure | 0 (0%) | 10 (4.6%) | NS |
| 30-Day Lesion Related Mortality | 1 (2.2%) | 1 (0.5%) | NS |
| 30-Day Disabling Stroke | 0 (0%) | 4 (1.9%) | NS |
| 30-Day New Dissection | 0 (0%) | 13 (6.0%) | NS |
| Late Type I/III Endoleak | 2 (4.3%) | 13 (6.0%) | NS |
| Late Aortic Rupture | 0 (0%) | 1 (0.5%) | NS |
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