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


Zimmermann, Alexander; Reutersberg, Benedikt (2022). Will the open revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair become obsolete? European Journal of Cardio-Thoracic Surgery, 62(2):ezac174.

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].

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].

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Additional indexing

Item Type:Journal Article, refereed, further contribution
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Vascular Surgery
Dewey Decimal Classification:610 Medicine & health
Scopus Subject Areas:Health Sciences > Surgery
Health Sciences > Pulmonary and Respiratory Medicine
Health Sciences > Cardiology and Cardiovascular Medicine
Uncontrolled Keywords:Cardiology and Cardiovascular Medicine, Pulmonary and Respiratory Medicine, General Medicine, Surgery
Language:English
Date:11 July 2022
Deposited On:31 Jan 2023 12:49
Last Modified:29 May 2024 01:46
Publisher:Oxford University Press
ISSN:1010-7940
OA Status:Closed
Free access at:Publisher DOI. An embargo period may apply.
Publisher DOI:https://doi.org/10.1093/ejcts/ezac174
PubMed ID:35352807