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Zone 2 Thoracic Endovascular Aortic Repair and Left Subclavian Artery Coverage: Revascularization Reduces Stroke Risk
Rhiannon J. Bradshaw, S. Sadie Ahanchi, David Dexter, Brandon Cain, Jean M. Panneton
EVMS, Norfolk, VA

Objective: The best management strategy for the left subclavian artery (LSCA) in pathologies of the aortic arch requiring zone 2 thoracic endovascular aortic repair (TEVAR) remains controversial. We compared LSCA coverage with or without revascularization.
Methods: A retrospective chart review was conducted of patients with all aortic pathologies who underwent zone 2 TEVAR deployment from 2007-2014. Primary outcomes included 30-day stroke, spinal cord injury (SCI), freedom from reintervention, aortic related mortality and all cause mortality.
Results: We identified 96 patients with zone 2 TEVAR that met our inclusion criteria. Mean patient age was 62 years, with 61.5% male. Pathologies included acute aortic dissections (n=25), chronic aortic dissection (n=22), aortic aneurysms (n=21), penetrating aortic ulcers/intramural hematomas (n=17), and traumatic aortic injuries (n=11).
Strategies for the LSCA in zone 2 TEVAR included coverage (n=41) or LSCA revascularization (n=55). Methods of LSCA revascularization included laser fenestration with stenting (n=33) and surgical revascularization: transposition (n=10) or bypass (n=12). There was no difference in demographics between the different LSCA treatment strategies. Of the 55 patients who underwent LSCA revascularization, 44 (45.8%) underwent LSCA intervention at the time of TEVAR, and 12 (12.5%) underwent LSCA intervention at a mean time of 33 days prior to TEVAR (range 4-63 days). For the entire 96 patient cohort, the overall incidence of 30-day stroke was 7.3% and 30-day SCI was 2.1%. At a mean follow up of 24 months (range 79 months), aortic-related reintervention was 16.7%, aortic related mortality was 13.5%, and all cause mortality was 29.2%.
Thirty-day risk of stroke was highest for LSCA coverage (6/41, 14.6%) compared to all forms of LSCA revascularization (1/55, 1.8% p=0.017). In terms of the 30-day stroke rate for the different methods of LSCA revascularization, no statistical difference was found between laser fenestration (1/33, 3.0%) versus surgical revascularization (0/22, 0% p=0.41). Lastly, no difference in stroke rate was observed in LSCA interventions done synchronous with TEVAR (1/44, 2.3%) versus LSCA interventions done metasynchronous with TEVAR (0/11, 0% p=0.614).
There was no difference in 30-day SCI between coverage (2/41, 4.9%) compared to all forms of LSCA revascularization (0/55, 0% p=0.098). In terms of the 30-day SCI for the different methods of LSCA revascularization, no statistical difference was found between laser fenestration (0/33, 0%) versus surgical revascularization (0/22, 0%). There was no difference in 2 year aortic related mortality between coverage (7/41, 17.1%) versus all forms of LSCA revascularization (5/55, 9.1% p=0.242). Although there was a significant difference between coverage (7/41, 17.1%) and surgical revascularization (0/22, 0% p=0.04). Lastly, no difference in SCI was observed in LSCA interventions done synchronous with TEVAR (0/44, 0%) versus LSCA interventions done metasynchronous with TEVAR (1/11, 9.1% p=0.20).
After univariate and multivariate analysis we identified complete or partial coverage as predictive of 30-day stroke (HR, 11.4: 95% confidence interval [CI], 1.355-92.215).
Conclusion: Our study suggests that complete or partial coverage of the LSCA increases the risk of stroke and possibly SCI. Laser fenestration and surgical LSCA revascularization, whether synchronous or metasynchronous, confer similar stroke protection.


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