Abstract
Background
Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases.
Methods
From December 2000 to June 2005, 11 patients (mean age, 57 ± 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery.
Results
SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 ± 17 mmHg. The stented length of the aorta was 171 ± 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 ± 8 months (range, 3–36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected.
Conclusion
Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.
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References
Biglioli P, Roberto M, Cannata A, Parolari A, Fumero A, Grillo F, Maggioni M, Coggi G, Spirito R (2004) Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries. J Thorac Cardiovasc Surg 127: 1188–1192
Biglioli P, Spirito R, Porqueddu M, Agrifoglio M, Pompilio G, Parolari A, Dainese L, Sisillo E (1999) Quick, simple clamping technique in descending thoracic aortic aneurysm repair. Ann Thorac Surg 67: 1038–1043
Brandt M, Hussel K, Walluscheck KP, Muller-Hulsbeck S, Jahnke T, Rahimi A, Cremer J (2004) Stent-graft repair versus open surgery for the descending aorta: a case–control study. J Endovasc Ther 11: 535–538
Cambria RP, Brewster DC, Lauterbach SR, Kaufman JL, Geller S, Fan CM, Greenfield A, Hilgenberg A, Clouse WD (2002) Evolving experience with thoracic aortic stent graft repair. J Vasc Surg 35: 1129–1136
Criado FJ, Clark NS, Barnatan MF (2002) Stent graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg 36: 1121–1128
Deriu GP, Milite D, Verlato F, Cognolato D, Frigatti P, Zaramella M, Mellone G, Greco F (1998) Surgical treatment of atherosclerotic lesions of subclavian artery: carotid–subclavian bypass versus subclavian–carotid transposition. J Cardiovasc Surg 39: 729–734
Fattori R, Napoli G, Lovato L, Grazia C, Piva T, Rocchi G, Angeli E, Di Bartolomeo R, Gavelli G (2003) Descending thoracic aortic diseases: stent-graft repair. Radiology 229: 176–183
Gorich J, Asquan Y, Seifarth H, Kramer S, Kapfer X, Orend KH, Sunder-Plassmann L, Pamler R (2002) Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther 9(Suppl 2): II39–II43
Heijmen RH, Deblier IG, Moll FL, Dossche KM, van den Berg JC, Overtoom TT, Ernst SM, Schepens MA (2002) Endovascular stent-grafting for descending thoracic aortic aneurysms. Eur J Cardiothorac Surg 21: 5–9
Inoue K, Hosokawa H, Iwase T, Sato M, Yoshida Y, Ueno K, Tsubokawa A, Tanaka T, Tamaki S, Suzuki T (1999) Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 100(Suppl): II316–II321
McWilliams RG, Murphy M, Hartley D, Lawrence-Brown MM, Harris PL (2004) In situ stent-graft fenestration to preserve the left subclavian artery. J Endovasc Ther 11: 170–174
Melissano G, Civilini E, Bertoglio L, Setacci F, Chiesa R (2005) Endovascular treatment of aortic arch aneurysms. Eur J Vasc Endovasc Surg 29: 131–138
Rehders TC, Petzsch M, Ince H, Kische S, Korber T, Koschyk DH, Chatterjee T, Weber F, Nienaber CA (2004) Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J Endovasc Ther 11: 659–666
Stanley BM, Semmens JB, Lawrence-Brown MM, Goodman MA, Hartley DE (2001) Fenestration in endovascular grafts for aortic aneurysm repair: new horizons for preserving blood flow in branch vessels. J Endovasc Ther 8: 16–24
Tiesenhausen K, Hausegger KA, Oberwalder P, Mahla E, Tomka M, Allmayer T, Baumann A, Hessinger M (2003) Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections. J Card Surg 18: 429–435
Tse LW, MacKenzie KS, Montreuil B, Obrand DI, Steinmetz OK (2004) The proximal landing zone in endovascular repair of the thoracic aorta. Ann Vasc Surg 18: 178–185
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Caronno, R., Piffaretti, G., Tozzi, M. et al. Intentional coverage of the left subclavian artery during endovascular stent graft repair for thoracic aortic disease. Surg Endosc 20, 915–918 (2006). https://doi.org/10.1007/s00464-005-0526-6
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DOI: https://doi.org/10.1007/s00464-005-0526-6