Will the open revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair become obsolete?

Abstract

Extract

For pathologies of the descending aorta, thoracic endovascular aortic repair (TEVAR) has become the first-line therapy. For long-term success, adequate proximal and distal landing zones are mandatory. In a retrospective study, it was shown that at least a length of 25–30 mm is necessary for the proximal landing zone for type II and III arches [1]. Since 40% of aortic pathologies extend to the left subclavian artery (LSA), revascularization of the LSA is often required to generate an adequate proximal landing zone [2]. LSA coverage without revascularization in the context of TEVAR implantation leads to a significantly increased 30-day risk of stroke and left arm ischaemia [3]. There are different open surgical and endovascular methods for revascularization of the LSA, which is also recommended by guidelines before TEVAR [4]. While open debranching uses carotid-subclavian bypasses or transpositions of the LSA, endovascular debranching has been performed using parallel graft techniques or physician-modified stent grafts. In a comparative study (open revascularization versus parallel graft technique), Dueppers et al. demonstrated that both techniques can achieve comparable reintervention and mortality rates. However, open debranching showed significantly higher rates of technical and clinical success and fewer type I endoleaks. This led to the recommendation that the open procedure should be preferred whenever possible [5]. But it should not be ignored that the open debranching procedure can also be associated with stroke rates of 2–9% and phrenic nerve injuries as high as 25% [6].